Healthcare Provider Details

I. General information

NPI: 1508577321
Provider Name (Legal Business Name): ORINOCO WELLNESS, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MAIN ST
GRAHAM NC
27253-2853
US

IV. Provider business mailing address

624 BONAVENTURE DR UNIT 302
MYRTLE BEACH SC
29577-9509
US

V. Phone/Fax

Practice location:
  • Phone: 336-265-6595
  • Fax:
Mailing address:
  • Phone: 336-613-7480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVEN J BARNES
Title or Position: PRESIDENT
Credential:
Phone: 336-265-6723