Provider Demographics
NPI:1861045767
Name:HAMMOCKS ON THE EDISTO LLC
Entity Type:Organization
Organization Name:HAMMOCKS ON THE EDISTO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CHIEF OF CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JONAS
Authorized Official - Last Name:COATSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LAC, CAC-II
Authorized Official - Phone:843-806-3414
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:JACKSONBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29452-0130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2137 HOPE PLANTATION LANE
Practice Address - Street 2:
Practice Address - City:JACKSONBORO
Practice Address - State:SC
Practice Address - Zip Code:29452
Practice Address - Country:US
Practice Address - Phone:843-276-9326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-19
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760493977Medicaid