Healthcare Provider Details

I. General information

NPI: 1225290109
Provider Name (Legal Business Name): ICHEP,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 HARDEN STREET EXT EXT., SUITE B18
COLUMBIA SC
29203-6894
US

IV. Provider business mailing address

108 CAUGHMAN RIDGE RD
COLUMBIA SC
29208-0001
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 Code283Q00000X
TaxonomyPsychiatric Hospital
License Number20083300132079
License Number StateSC

VIII. Authorized Official

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