NPIMap

Organization Active NPI

Excalibur Youth Services, LLC.

  • Family Medicine Physician
  • Simpsonville, SC
National Provider Identifier
1487174462
Registry record updated Jun 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
EXCALIBUR YOUTH SERVICES, LLC.
Practice address
3683 S Industrial Dr
Simpsonville, SC 29681-3238
Phone
(864) 836-7220
NPI assigned
Jun 21, 2017
Last updated
Jun 21, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 21, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John M Short
Title
Ceo
Phone
(864) 836-7220

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X SC Primary

Addresses

Primary practice location

3683 S Industrial Dr
Simpsonville, SC 29681-3238

Mailing address

PO Box 968
Travelers Rest, SC 29690-0968
Phone (864) 836-7220

Other identifiers 1

IdentifierTypeStateIssuer
1083852511MedicaidSC

National Provider Directory

National Provider Directory
Tax ID family
Excalibur Youth Services LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1498003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1498003200000",
    "number": "1487174462",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 968",
            "city": "TRAVELERS REST",
            "state": "SC",
            "postal_code": "296900968",
            "telephone_number": "864-836-7220"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3683 S INDUSTRIAL DR",
            "city": "SIMPSONVILLE",
            "state": "SC",
            "postal_code": "296813238",
            "telephone_number": "864-836-7220"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXCALIBUR YOUTH SERVICES, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-21",
        "last_updated": "2017-06-21",
        "status": "A",
        "authorized_official_last_name": "SHORT",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "864-836-7220"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1083852511",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Simpsonville, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.