Provider Demographics
NPI:1629529698
Name:CLARENDON BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:CLARENDON BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERUM CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-435-2121
Mailing Address - Street 1:14 N. CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102
Mailing Address - Country:US
Mailing Address - Phone:803-435-2121
Mailing Address - Fax:803-435-8856
Practice Address - Street 1:14 N. CHURCH STREET
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102
Practice Address - Country:US
Practice Address - Phone:803-435-2121
Practice Address - Fax:803-435-8856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1730176934Medicaid