MEDICARE: CHIKAKO OKUMURA RIESTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	R200655	MD
2	363LA2200X	Adult Health Nurse Practitioner	24189	SC

General Provider Information

NPI Number	:	1386997542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIKAKO OKUMURA RIESTER

Provider Business Mailing Address
First Line	:	2001 2ND AVE STE 201
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7887
Country	:	US
Telephone Number	:	843-572-4840
Fax Number	:	843-764-2726

Provider Business Practice Location Address
First Line	:	2001 2ND AVE STE 201
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7887
Country	:	US
Telephone Number	:	843-572-4840
Fax Number	:	843-764-2726

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2012
Last Update Date	:	11/12/2020

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