Provider Demographics
NPI:1710027578
Name:SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
Entity Type:Organization
Organization Name:SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
Other - Org Name:DJJ GREENVILLE GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAID PROJECT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-896-4751
Mailing Address - Street 1:PO BOX 21069
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29221-1069
Mailing Address - Country:US
Mailing Address - Phone:803-896-4751
Mailing Address - Fax:803-896-8473
Practice Address - Street 1:423 VARDRY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3307
Practice Address - Country:US
Practice Address - Phone:864-233-5574
Practice Address - Fax:864-233-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDJJ058Medicaid