Healthcare Provider Details

I. General information

NPI: 1205260304
Provider Name (Legal Business Name): CHANNEL THE BEACON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 RIVERS AVE SUITE 1408
NORTH CHARLESTON SC
29406-4809
US

IV. Provider business mailing address

PO BOX 41294
NORTH CHARLESTON SC
29423-1294
US

V. Phone/Fax

Practice location:
  • Phone: 843-576-1408
  • Fax: 843-278-9275
Mailing address:
  • Phone: 843-330-1522
  • Fax: 843-278-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateSC

VIII. Authorized Official

Name: JOHNETTE S SIMMONS
Title or Position: EXECUTIVE DIRECTOR
Credential: BS, MBA, DHA
Phone: 843-330-1522