Provider Demographics
NPI:1669519518
Name:CLARENDON ONE
Entity type:Organization
Organization Name:CLARENDON ONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-485-2325
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:12 SOUTH CHURCH STREET
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-0038
Mailing Address - Country:US
Mailing Address - Phone:803-485-2325
Mailing Address - Fax:803-485-7065
Practice Address - Street 1:12 SOUTH CHURCH STREET
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148-0038
Practice Address - Country:US
Practice Address - Phone:803-485-2325
Practice Address - Fax:803-485-7065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSD1401Medicaid