=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528517711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RALPH H. JOHNSON VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2016
-----------------------------------------------------
Last Update Date | 09/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 BEE ST.
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-789-7393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8531 SENTRY CIRCLE
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-864-1554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | DANIELLE RENEE STREAKS
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 843-789-7393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | 11769
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------