Provider Demographics
NPI:1710023833
Name:WIL LOU GRAY OPPORTUNITY SCHOOL
Entity Type:Organization
Organization Name:WIL LOU GRAY OPPORTUNITY SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MEDICAL SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-896-6472
Mailing Address - Street 1:3300 W CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2134
Mailing Address - Country:US
Mailing Address - Phone:803-896-6480
Mailing Address - Fax:803-896-6494
Practice Address - Street 1:3300 W CAMPUS RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-2134
Practice Address - Country:US
Practice Address - Phone:803-896-6480
Practice Address - Fax:803-896-6494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVR0001Medicaid