Provider Demographics
NPI:1972524957
Name:WINDWOOD FARM HOME
Entity Type:Organization
Organization Name:WINDWOOD FARM HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKELVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-884-5342
Mailing Address - Street 1:4857 WINDWOOD FARM RD
Mailing Address - Street 2:
Mailing Address - City:AWENDAW
Mailing Address - State:SC
Mailing Address - Zip Code:29429-5951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4857 WINDWOOD FARM RD
Practice Address - Street 2:
Practice Address - City:AWENDAW
Practice Address - State:SC
Practice Address - Zip Code:29429-5951
Practice Address - Country:US
Practice Address - Phone:843-884-5342
Practice Address - Fax:843-884-1287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSR-0008106001-CCI320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4441Medicaid