1104145184 NPI number — TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.

Table of content: (NPI 1104145184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104145184 NPI number — TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104145184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVELERS REST
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29690-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-908-6372
Provider Business Mailing Address Fax Number:
864-898-3703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVELERS REST
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29690-1826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-908-6372
Provider Business Practice Location Address Fax Number:
864-898-3703
Provider Enumeration Date:
05/31/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DIMITROVA
Authorized Official First Name:
GERGANA
Authorized Official Middle Name:
DAMIANOVA
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
864-908-6372

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1223 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 5825 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 30719 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0805X , with the licence number: 30719 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)