Provider Demographics
NPI:1245779164
Name:GRACEFUL LIVING BEHAVIORAL SUPPORT
Entity Type:Organization
Organization Name:GRACEFUL LIVING BEHAVIORAL SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:SARUMI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MPH
Authorized Official - Phone:843-576-5392
Mailing Address - Street 1:3236 LANDMARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-8488
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3236 LANDMARK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-8488
Practice Address - Country:US
Practice Address - Phone:843-576-5392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health