1205260304 NPI number — CHANNEL THE BEACON

Table of content: (NPI 1205260304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205260304 NPI number — CHANNEL THE BEACON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANNEL THE BEACON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205260304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29423-1294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-330-1522
Provider Business Mailing Address Fax Number:
843-278-9275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6650 RIVERS AVE
Provider Second Line Business Practice Location Address:
SUITE 1408
Provider Business Practice Location Address City Name:
NORTH CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-576-1408
Provider Business Practice Location Address Fax Number:
843-278-9275
Provider Enumeration Date:
08/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SIMMONS
Authorized Official First Name:
JOHNETTE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
843-330-1522

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , 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)

  • Identifier: CM1007 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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