1689216863 NPI number — LIVE FOR WELLNESS JOHNS ISLAND

Table of content: (NPI 1689216863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689216863 NPI number — LIVE FOR WELLNESS JOHNS ISLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVE FOR WELLNESS JOHNS ISLAND
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:
1689216863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3417 SHELBY RAY CT STE C
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:
29414-5895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-737-6960
Provider Business Mailing Address Fax Number:
843-737-6960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1803 CROWNE COMMONS WAY
Provider Second Line Business Practice Location Address:
SUITE 1-A
Provider Business Practice Location Address City Name:
JOHNS ISLAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-737-6960
Provider Business Practice Location Address Fax Number:
843-737-6960
Provider Enumeration Date:
10/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PERDUE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-737-6960

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)

  • Identifier: CH3757 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124551064 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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