Basic Information
Provider Information | |||||||||
NPI: | 1083083117 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHOW | ||||||||
FirstName: | CALLA | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANDERS | ||||||||
OtherFirstName: | CALLA | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1905 FRANCIS ST | ||||||||
Address2: |   | ||||||||
City: | ORANGEBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 291181931 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238959553 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1742 VILLAGE PARK DRIVE | ||||||||
Address2: |   | ||||||||
City: | ORANGEBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 291181931 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8039970856 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/18/2015 | ||||||||
LastUpdateDate: | 08/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 187636 | TN | N |   | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 363LG0600X | 19752 | SC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LC0200X | 19752 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 19752 | 01 | SC | MEDICAL LICENSE | OTHER | NP3492 | 05 | SC |   | MEDICAID |