# EXCALIBUR YOUTH SERVICES, LLC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1710063375
- **Authorized official:** MR. MARVIN J. SHORT III (MEMBER)
- **Authorized official phone:** (864) 679-0023

## Contact information

- **Practice address:** 5321 OLD BUNCOMBE RD, GREENVILLE, SC 29609-0910
- **Practice address phone:** (864) 679-0023
- **Practice address fax:** (864) 294-1774
- **Mailing address:** PO BOX 968, MARIETTA, SC 29661-0968
- **Mailing address phone:** (864) 679-0023
- **Mailing address fax:** (864) 294-1774

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320800000X | Mental Illness Community Based Residential Treatment Facility | — | NULL | — |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | SR-0009711001-CCI | SC | Yes |

## Other

- **Enumeration date:** 10/27/2006
- **Last updated:** 03/11/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 907MXH | — | SC |