MEDICARE: SOUTHERN CHARM MEDICAL AND WELLNESS, 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	363LF0000X	Family Nurse Practitioner
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22378	OTHER	SC	SC APRN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659121614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CHARM MEDICAL AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	211 S PEARL ST STE B
Second Line	:
City	:	PAGELAND
State	:	SC
Zip	:	29728-2261
Country	:	US
Telephone Number	:	843-675-5070
Fax Number	:	989-214-7326

Provider Business Practice Location Address
First Line	:	211 S PEARL ST STE B
Second Line	:
City	:	PAGELAND
State	:	SC
Zip	:	29728-2261
Country	:	US
Telephone Number	:	843-675-5070
Fax Number	:	989-214-7326

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL B CLARK
Credential	:	FNP-C
Telephone Number	:	843-675-5070

Provider Enumeration Date	:	03/25/2024
Last Update Date	:	06/15/2026

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