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General NPI Number Information
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NPI Number | 1225290109
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Entity Type | Organization
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Legal Business Name | ICHEP,LLC
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Dates
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Enumeration Date | 07/01/2008
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Last Update Date | 07/01/2008
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Provider Practice Location Address
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Address Line | 3555 HARDEN STREET EXT EXT., SUITE B18
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City | COLUMBIA
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State | SC
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Zip | 29203-6894
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Country | US
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Telephone | 803-477-7928
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Fax |
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Provider Business Mailing Address
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Address Line | 108 CAUGHMAN RIDGE RD
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City | COLUMBIA
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State | SC
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Zip | 29208-0001
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Country | US
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Telephone | 803-477-7928
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SHAKA ABDUL MOUSTAFA I
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Credential | PH.D
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Telephone | 803-477-7928
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number | 20083300132079
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License Number State | SC
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