1942752076 NPI number — DR. CHARITA MONICA JOHNSON APRN

Table of content: DR. CHARITA MONICA JOHNSON APRN (NPI 1942752076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942752076 NPI number — DR. CHARITA MONICA JOHNSON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
CHARITA
Provider Middle Name:
MONICA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942752076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1624 MAIN STREET
Provider Second Line Business Mailing Address:
AGAPE SENIOR PRIMARY CARE, INC., DBA LTC HEALTH SOLUTIO
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-726-2350
Provider Business Mailing Address Fax Number:
803-404-6000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1317 EBENEZER RD
Provider Second Line Business Practice Location Address:
LTC HEALTH SOLUTIONS
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-207-8200
Provider Business Practice Location Address Fax Number:
803-207-8207
Provider Enumeration Date:
10/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  20548 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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