Basic Information
| Provider Information | |||||||||
| NPI: | 1730660671 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, MDPP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 357 | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299362605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 719 OKATIE HWY # 170 | ||||||||
| Address2: | |||||||||
| City: | OKATIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299093963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2018 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | ROLAND | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8439877400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | DPE064 | 05 | SC | MEDICAID |