Organization
EXCALIBUR YOUTH SERVICES, LLC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARVIN J. SHORT III (MEMBER)
(864) 679-0023
Entity
Organization
Contact information
Practice address
5321 OLD BUNCOMBE RD, GREENVILLE, SC 29609-0910
(864) 679-0023
(864) 294-1774
Mailing address
PO BOX 968, MARIETTA, SC 29661-0968
(864) 679-0023
(864) 294-1774
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
SR-0009711001-CCI
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
907MXH
—
SC
Enumeration date
10/27/2006
Last updated
03/11/2008
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