Provider Demographics
NPI:1609059989
Name:SOUTH CAROLINA CENTER FOR GRASSROOTS
Entity Type:Organization
Organization Name:SOUTH CAROLINA CENTER FOR GRASSROOTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-454-1130
Mailing Address - Street 1:1105 BELLEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1839
Mailing Address - Country:US
Mailing Address - Phone:803-454-1130
Mailing Address - Fax:
Practice Address - Street 1:1105 BELLEVIEW ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1839
Practice Address - Country:US
Practice Address - Phone:803-454-1130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty