Provider Demographics
NPI:1972753622
Name:ROCK HILL VA
Entity type:Organization
Organization Name:ROCK HILL VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAWNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-366-4848
Mailing Address - Street 1:205 PIEDMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 PIEDMONT BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1836
Practice Address - Country:US
Practice Address - Phone:803-366-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQMO740Medicaid