MEDICARE: CAROLINA HEALTH AND WELLNESS SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043804388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA HEALTH AND WELLNESS SERVICES, LLC

Provider Business Mailing Address
First Line	:	2754 MAYBANK HWY STE B
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-996-4908
Fax Number	:	843-962-5450

Provider Business Practice Location Address
First Line	:	2754 MAYBANK HWY STE B
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-996-4908
Fax Number	:	843-962-5450

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	DR. BLAKE DOUGLAS DEVOLLD
Credential	:	ED.D.
Telephone Number	:	843-996-4908

Provider Enumeration Date	:	02/26/2021
Last Update Date	:	02/26/2021

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