Healthcare Provider Details

I. General information

NPI: 1134319726
Provider Name (Legal Business Name): VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

109 BEE ST
CHARLESTON SC
29401-5703
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-7065
  • Fax:
Mailing address:
  • Phone: 843-789-7065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberL0003005
License Number StateMD

VIII. Authorized Official

Name: DUSTYN NICOLE OWENS
Title or Position: NURSE RECRUITER
Credential:
Phone: 843-789-7065