Basic Information
Provider Information | |||||||||
NPI: | 1538801527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENSLEY | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | AMOS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2720 SUNSET BLVD | ||||||||
Address2: |   | ||||||||
City: | WEST COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 291694810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037912000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 146 E HOSPITAL DR STE 140&350 | ||||||||
Address2: |   | ||||||||
City: | WEST COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 291694800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8039367230 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2022 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 98413 | SC | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 26109 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.