Provider Demographics
NPI:1790848646
Name:SC DEPT OF DISABILITIES & SPECIAL NEEDS
Entity Type:Organization
Organization Name:SC DEPT OF DISABILITIES & SPECIAL NEEDS
Other - Org Name:CLINTON MANOR COMMUNITY RESIDENCE
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY STATE DIRECTOR ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BARFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-898-9743
Mailing Address - Street 1:POST OFFICE BOX 4706
Mailing Address - Street 2:3440 HARDEN STREET EXTENSION
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29240-4706
Mailing Address - Country:US
Mailing Address - Phone:803-898-9600
Mailing Address - Fax:803-898-9653
Practice Address - Street 1:3440 HARDEN STREET EXTENSION
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-898-9600
Practice Address - Fax:803-898-9653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0735NHMedicaid