Provider Demographics
NPI:1851349567
Name:CAROLINA BOYS HOME INC
Entity Type:Organization
Organization Name:CAROLINA BOYS HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-786-7100
Mailing Address - Street 1:PO BOX 3355
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3355
Mailing Address - Country:US
Mailing Address - Phone:803-786-7100
Mailing Address - Fax:803-333-0033
Practice Address - Street 1:1303 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4252
Practice Address - Country:US
Practice Address - Phone:803-786-7100
Practice Address - Fax:803-333-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSR0001731001GH322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC911MXHMedicaid