Healthcare Provider Details

I. General information

NPI: 1134517329
Provider Name (Legal Business Name): RALPH H. JOHNSON VETERANS AFFAIRS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
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: 843-577-5001
  • Fax:
Mailing address:
  • Phone: 843-577-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number10576
License Number StateSC

VIII. Authorized Official

Name: MRS. SANDRA LORRAINE MINTER
Title or Position: SOCIAL WORKER
Credential: LISW-CP
Phone: 843-577-5011