Provider Demographics
NPI:1447654363
Name:NEW DOMINION COMMUNITY SERVICES LLC
Entity type:Organization
Organization Name:NEW DOMINION COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IDRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TALIB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-847-1818
Mailing Address - Street 1:900 GREENVILLE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29697-1130
Mailing Address - Country:US
Mailing Address - Phone:864-847-1818
Mailing Address - Fax:678-550-9865
Practice Address - Street 1:900 GREENVILLE DRIVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-0000
Practice Address - Country:US
Practice Address - Phone:864-847-1818
Practice Address - Fax:678-550-9865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6646Medicaid