Provider Demographics
NPI:1205260304
Name:CHANNEL THE BEACON
Entity type:Organization
Organization Name:CHANNEL THE BEACON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MBA, DHA
Authorized Official - Phone:843-330-1522
Mailing Address - Street 1:PO BOX 41294
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-1294
Mailing Address - Country:US
Mailing Address - Phone:843-330-1522
Mailing Address - Fax:843-278-9275
Practice Address - Street 1:6650 RIVERS AVE
Practice Address - Street 2:SUITE 1408
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4809
Practice Address - Country:US
Practice Address - Phone:843-576-1408
Practice Address - Fax:843-278-9275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251V00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCM1007Medicaid