Provider Demographics
NPI:1366764870
Name:KIVA LODGE
Entity type:Organization
Organization Name:KIVA LODGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CARE PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:Z
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-754-5478
Mailing Address - Street 1:11 S FIRETOWER CT
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016
Mailing Address - Country:US
Mailing Address - Phone:803-754-2328
Mailing Address - Fax:803-754-2328
Practice Address - Street 1:200 CLAUDE BUNDRICK RD
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-9420
Practice Address - Country:US
Practice Address - Phone:803-754-5478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CTHII
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health