Provider Demographics
NPI:1508017476
Name:AVALONIA GROUP HOMES, INC.
Entity Type:Organization
Organization Name:AVALONIA GROUP HOMES, INC.
Other - Org Name:HAMPTON P.R.T.F.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:III
Authorized Official - Credentials:JD
Authorized Official - Phone:864-313-6967
Mailing Address - Street 1:PO BOX 1214
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-1214
Mailing Address - Country:US
Mailing Address - Phone:864-897-8050
Mailing Address - Fax:864-878-7276
Practice Address - Street 1:404 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:PICKENS
Practice Address - State:SC
Practice Address - Zip Code:29671-2608
Practice Address - Country:US
Practice Address - Phone:864-897-8050
Practice Address - Fax:864-878-7276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRTF-0020323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRTF-0020OtherSOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIORNMENTAL CONTROL