Provider Demographics
NPI:1710063375
Name:EXCALIBUR YOUTH SERVICES, LLC.
Entity Type:Organization
Organization Name:EXCALIBUR YOUTH SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:864-679-0023
Mailing Address - Street 1:PO BOX 968
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29661-0968
Mailing Address - Country:US
Mailing Address - Phone:864-679-0023
Mailing Address - Fax:864-294-1774
Practice Address - Street 1:5321 OLD BUNCOMBE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-0910
Practice Address - Country:US
Practice Address - Phone:864-679-0023
Practice Address - Fax:864-294-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X
SCSR-0009711001-CCI322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC907MXHMedicaid