Provider Demographics
NPI:1386997591
Name:BAMBERG JOB CORP.
Entity type:Organization
Organization Name:BAMBERG JOB CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:803-531-6900
Mailing Address - Street 1:3310 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-1466
Mailing Address - Country:US
Mailing Address - Phone:803-531-6900
Mailing Address - Fax:
Practice Address - Street 1:19 JOB CORPS AVE
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1606
Practice Address - Country:US
Practice Address - Phone:803-245-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty