Provider Demographics
NPI:1790481422
Name:864PRIDE
Entity Type:Organization
Organization Name:864PRIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:864-325-1356
Mailing Address - Street 1:30 POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3506
Mailing Address - Country:US
Mailing Address - Phone:864-325-1356
Mailing Address - Fax:864-655-5183
Practice Address - Street 1:30 POINTE CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3506
Practice Address - Country:US
Practice Address - Phone:864-655-5193
Practice Address - Fax:864-655-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)