Basic Information
| Provider Information | |||||||||
| NPI: | 1689878357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KERSHAWHEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | DIABETES EDUCATIONAL PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 ROBERTS ST | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290203737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034324311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1315 ROBERTS ST | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290203737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034324311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 09/23/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEEKS | ||||||||
| AuthorizedOfficialFirstName: | DONNIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8037132065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | ID#005277 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | DPE066 | 05 | SC | MEDICAID |