MEDICARE: WEST ASHLEY WELLNESS & REHABILITATION, 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	111NR0400X	Rehabilitation Chiropractor	2265	SC
2	225400000X	Rehabilitation Practitioner	23765	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1083641914	OTHER	SC	INDIVIDUAL NPI
2	1427030212	OTHER	SC	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1962726117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST ASHLEY WELLNESS & REHABILITATION, LLC

Provider Business Mailing Address
First Line	:	2 CARRIAGE LN
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-6010
Country	:	US
Telephone Number	:	843-571-3100
Fax Number	:	843-766-7798

Provider Business Practice Location Address
First Line	:	2 CARRIAGE LN
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-6010
Country	:	US
Telephone Number	:	843-571-3100
Fax Number	:	843-766-7798

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KAREN R LUCKIE
Credential	:
Telephone Number	:	843-571-3100

Provider Enumeration Date	:	03/17/2010
Last Update Date	:	02/10/2015

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