Provider Demographics
NPI:1831639459
Name:UPSTATE AFFILIATE ORGANIZATION
Entity Type:Organization
Organization Name:UPSTATE AFFILIATE ORGANIZATION
Other - Org Name:GHS KIDNETICS - SPARTANBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE - CORPORATE
Authorized Official - Prefix:
Authorized Official - First Name:SPENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-797-6118
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6307
Mailing Address - Fax:
Practice Address - Street 1:249 N GROVE MEDICAL PARK DR
Practice Address - Street 2:#300
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4227
Practice Address - Country:US
Practice Address - Phone:864-598-0420
Practice Address - Fax:864-598-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-0936261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities