1124771159 NPI number — ISLAND EXPERIENCE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124771159 NPI number — ISLAND EXPERIENCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND EXPERIENCE, INC.
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:
CHARLESTON WELLNESS CENTER
Provider Other Organization Name Type Code:
3
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:
1124771159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29422-4333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-588-1230
Provider Business Mailing Address Fax Number:
843-588-5550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 FOLLY RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29412-3938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-588-1230
Provider Business Practice Location Address Fax Number:
843-588-5550
Provider Enumeration Date:
01/31/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HAMBROOK
Authorized Official First Name:
MANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
864-569-9621

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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