NPIMap

Organization Active NPI

Excalibur Youth Services, LLC.

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Greenville, SC
National Provider Identifier
1710063375
Registry record updated Mar 11, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emotionally Disturbed Childrens' Residential Treatment FacilityTaxonomy code 322D00000X
License
SR-0009711001-CCI Issued in SC
Legal business name
EXCALIBUR YOUTH SERVICES, LLC.
Practice address
5321 Old Buncombe Rd
Greenville, SC 29609-0910
Phone
(864) 679-0023
Fax
(864) 294-1774
NPI assigned
Oct 27, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2008

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

Authorized official

Name
Mr. Marvin J. Short III
Title
Member
Phone
(864) 679-0023

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Illness Community Based Residential Treatment Facility 320800000X
Emotionally Disturbed Childrens' Residential Treatment Facility 322D00000X SR-0009711001-CCI SC Primary

Addresses

Primary practice location

5321 Old Buncombe Rd
Greenville, SC 29609-0910

Mailing address

PO Box 968
Marietta, SC 29661-0968
Phone (864) 679-0023

Other identifiers 1

IdentifierTypeStateIssuer
907MXHMedicaidSC

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": "1161907200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1205193600000",
    "number": "1710063375",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 968",
            "city": "MARIETTA",
            "state": "SC",
            "postal_code": "296610968",
            "telephone_number": "864-679-0023",
            "fax_number": "864-294-1774"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5321 OLD BUNCOMBE RD",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296090910",
            "telephone_number": "864-679-0023",
            "fax_number": "864-294-1774"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXCALIBUR YOUTH SERVICES, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-27",
        "last_updated": "2008-03-11",
        "status": "A",
        "authorized_official_last_name": "SHORT",
        "authorized_official_first_name": "MARVIN",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "864-679-0023",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "SC",
            "license": "SR-0009711001-CCI",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "907MXH",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Greenville, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2008; 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.