1407342116 NPI number — THRIVE ESSENTIAL WELLNESS, INC.

Table of content: (NPI 1407342116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407342116 NPI number — THRIVE ESSENTIAL WELLNESS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIVE ESSENTIAL WELLNESS, 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:
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:
1407342116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1511 9TH AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-4126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-488-1894
Provider Business Mailing Address Fax Number:
843-488-2786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1511 9TH AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-488-1894
Provider Business Practice Location Address Fax Number:
843-488-2786
Provider Enumeration Date:
07/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TALLENT
Authorized Official First Name:
GREG
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PA-C, VICE PRESIDENT
Authorized Official Telephone Number:
843-251-6688

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1942532023 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1942532023 . This is a "BC/BS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1245535574 . This is a "BC/BS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1982716586 . This is a "BC/BS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1245535574 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1982716585 . This is a "BC/BS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1982716585 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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