Healthcare Provider Details

I. General information

NPI: 1528517711
Provider Name (Legal Business Name): RALPH H. JOHNSON VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST.
CHARLESTON SC
29401
US

IV. Provider business mailing address

8531 SENTRY CIRCLE
NORTH CHARLESTON SC
29420
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-7393
  • Fax:
Mailing address:
  • Phone: 843-864-1554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number11769
License Number StateSC

VIII. Authorized Official

Name: DANIELLE RENEE STREAKS
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 843-789-7393