=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144500190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOSEN ONES BY GOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2011
-----------------------------------------------------
Last Update Date | 08/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 CHACE AVE
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-4491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-323-2723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 CHACE AVE
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-4491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-323-2723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. DEMARCO RESHARD RYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-323-2723
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------