=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205260304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANNEL THE BEACON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2013
-----------------------------------------------------
Last Update Date | 09/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6650 RIVERS AVE SUITE 1408
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-576-1408
-----------------------------------------------------
Fax | 843-278-9275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 41294
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29423-1294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-330-1522
-----------------------------------------------------
Fax | 843-278-9275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JOHNETTE S SIMMONS
-----------------------------------------------------
Credential | BS, MBA, DHA
-----------------------------------------------------
Telephone | 843-330-1522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------