Provider Demographics
NPI:1841443181
Name:ICHEP LLC
Entity type:Organization
Organization Name:ICHEP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAKA
Authorized Official - Middle Name:ABDUL
Authorized Official - Last Name:MOUSTAFA
Authorized Official - Suffix:I
Authorized Official - Credentials:PHD
Authorized Official - Phone:803-477-7928
Mailing Address - Street 1:9635 SOUTHERN PINE BLVD
Mailing Address - Street 2:SUITE 126
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-5558
Mailing Address - Country:US
Mailing Address - Phone:803-477-7928
Mailing Address - Fax:
Practice Address - Street 1:9635 SOUTHERN PINE BLVD STE 126
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-5558
Practice Address - Country:US
Practice Address - Phone:803-477-7928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health