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General NPI Number Information
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NPI Number | 1114214665
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Entity Type | Organization
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Legal Business Name | GENPSYCH OF SOUTH CAROLINA, LLC
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Dates
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Enumeration Date | 07/06/2011
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Last Update Date | 07/06/2011
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Provider Practice Location Address
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Address Line | 2 MEDICAL CT
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City | SUMTER
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State | SC
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Zip | 29150-4760
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Country | US
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Telephone | 803-774-4020
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Fax | 803-774-4025
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Provider Business Mailing Address
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Address Line | 2 MEDICAL CT
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City | SUMTER
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State | SC
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Zip | 29150-4760
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Country | US
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Telephone | 803-774-4020
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Fax | 803-774-4025
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Authorized Official
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Title or Position | CEO
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Name | DR. HENRY ODUNLAMI
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Credential | M.D.
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Telephone | 908-231-0511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 21075
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License Number State | SC
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