Provider Demographics
NPI:1588792030
Name:CAROLINA CTR FOR OCCUP HEALTH
Entity type:Organization
Organization Name:CAROLINA CTR FOR OCCUP HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAYTON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-554-1029
Mailing Address - Street 1:4600 GOER DR
Mailing Address - Street 2:STE. 205
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6500
Mailing Address - Country:US
Mailing Address - Phone:843-554-1029
Mailing Address - Fax:843-554-1103
Practice Address - Street 1:4600 GOER DR
Practice Address - Street 2:STE. 205
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6500
Practice Address - Country:US
Practice Address - Phone:843-554-1029
Practice Address - Fax:843-554-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC67825305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0280Medicaid
6684Medicare PIN