MEDICARE: WELLNESSONE ANCILLARY 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1285973255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESSONE ANCILLARY SERVICES LLC

Provider Business Mailing Address
First Line	:	4736A HIGHWAY 17 BYP S
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-5616
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4736A HIGHWAY 17 BYP S
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-5616
Country	:	US
Telephone Number	:	843-444-9355
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DARIN GREEN
Credential	:
Telephone Number	:	843-444-9355

Provider Enumeration Date	:	02/11/2013
Last Update Date	:	04/09/2013

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