Organization
EXCALIBUR YOUTH SERVICES, LLC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN M SHORT (CEO)
(864) 836-7220
Entity
Organization
Contact information
Practice address
3683 S INDUSTRIAL DR, SIMPSONVILLE, SC 29681-3238
(864) 836-7220
Mailing address
PO BOX 968, TRAVELERS REST, SC 29690-0968
(864) 836-7220
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1083852511
—
SC
Enumeration date
06/21/2017
Last updated
06/21/2017
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