Healthcare Provider Details

I. General information

NPI: 1508235110
Provider Name (Legal Business Name): HEALTH ACCESS 360, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 FOREST DR STE 3-276
COLUMBIA SC
29206-3125
US

IV. Provider business mailing address

4711 FOREST DR STE 3-276
COLUMBIA SC
29206-3125
US

V. Phone/Fax

Practice location:
  • Phone: 803-261-1291
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number261QHO100X
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number261QM0850X
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number261QM0855X
License Number StateSC

VIII. Authorized Official

Name: DR. PIERRE H BARAKAT
Title or Position: BUSINESS ASSOCIATE
Credential:
Phone: 803-261-1291