Provider Demographics
NPI:1710291372
Name:TRI-COUNTY COMMISSION ON ALCOHOL AND DRUG ABUSE
Entity Type:Organization
Organization Name:TRI-COUNTY COMMISSION ON ALCOHOL AND DRUG ABUSE
Other - Org Name:WLLIAM J. MCCORD ADOLESCENT TREATMENT FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-536-4900
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1166
Mailing Address - Country:US
Mailing Address - Phone:803-536-4900
Mailing Address - Fax:803-531-8419
Practice Address - Street 1:910 COOK ROAD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118
Practice Address - Country:US
Practice Address - Phone:803-536-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-0619283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCM00036SC1Medicaid