Provider Demographics
NPI:1558881524
Name:AVALONIA GROUP HOMES, INC.
Entity Type:Organization
Organization Name:AVALONIA GROUP HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-313-5274
Mailing Address - Street 1:PO BOX 968
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-0968
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:864-836-7220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1083852511Medicaid