=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730284480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARRT,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 10/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 CENTRE SOUTH BLVD
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29803-6313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-642-4045
-----------------------------------------------------
Fax | 803-642-4041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 SAINT SEBASTIAN WAY SUITE 5A
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901-2643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-724-4045
-----------------------------------------------------
Fax | 706-724-4041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEPHANIE B WOOLLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-724-4045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 042002
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 15566
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------