Provider Demographics
NPI:1508931312
Name:BRAODSTEP ACADEMY -SOUTH CAROLINA INC
Entity Type:Organization
Organization Name:BRAODSTEP ACADEMY -SOUTH CAROLINA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:KEDRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-709-0197
Mailing Address - Street 1:1991 GLENNS BAY RD STE 101A
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-8614
Mailing Address - Country:US
Mailing Address - Phone:843-215-0242
Mailing Address - Fax:843-215-0017
Practice Address - Street 1:1991 GLENNS BAY RD STE 101A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-8614
Practice Address - Country:US
Practice Address - Phone:843-215-0242
Practice Address - Fax:843-215-0017
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROADSTEP ACADEMY- SOUTH CAROLINA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
SCSR0008521001CCI322D00000X
SC322D00000X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC883MXHMedicaid