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430 Herlong Ave S Ste 102 Rock Hill SC 29732-1094 | |
| (803) 324-7707 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 430 Herlong Ave S Ste 102, Rock Hill, South Carolina |
| Authorized Official Name and Position | Angie Mattingly (MANAGER-PROVIDER ENROLLMENT) |
| Authorized Official Contact | 5026307425 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
805 N Whittington Pkwy Louisville KY 40222-5186 Ph: (800) 866-0860 | 430 Herlong Ave S Ste 102 Rock Hill SC 29732-1094 Ph: (803) 324-7707 |
| NPI Number | 1295064608 |
|---|---|
| Provider Enumeration Date | 12/14/2009 |
| Last Update Date | 03/04/2020 |
| Certification Date | 03/04/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295064608 | NPI | - | NPPES |
| EX0694 | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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