Provider Demographics
NPI:1770390304
Name:GRAND PALACE ACTIVITY CENTER
Entity type:Organization
Organization Name:GRAND PALACE ACTIVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-491-4426
Mailing Address - Street 1:1105 VINTAGE DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-6121
Mailing Address - Country:US
Mailing Address - Phone:803-491-4426
Mailing Address - Fax:
Practice Address - Street 1:1127 OLD POCALLO RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-7519
Practice Address - Country:US
Practice Address - Phone:803-491-4426
Practice Address - Fax:803-774-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services