Healthcare Provider Details

I. General information

NPI: 1609267822
Provider Name (Legal Business Name): PALMETTO COMPREHENSIVE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CAUGHMAN RIDGE RD
COLUMBIA SC
29209-3114
US

IV. Provider business mailing address

108 CAUGHMAN RIDGE RD
COLUMBIA SC
29209-3114
US

V. Phone/Fax

Practice location:
  • Phone: 803-477-7928
  • Fax:
Mailing address:
  • Phone: 803-477-7928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAKA ABDUL MOUSTAFA I
Title or Position: CEO/OWNER
Credential: PH.D.
Phone: 803-477-7928