Healthcare Provider Details

I. General information

NPI: 1629639760
Provider Name (Legal Business Name): ST JAMES HEALTH AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13072 COUNTY LINE RD
ANDREWS SC
29510-6811
US

IV. Provider business mailing address

PO BOX 608
MC CLELLANVILLE SC
29458-0608
US

V. Phone/Fax

Practice location:
  • Phone: 843-990-7993
  • Fax: 843-887-3817
Mailing address:
  • Phone: 843-887-3274
  • Fax: 843-887-3817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SANDRA D GILLIARD
Title or Position: CEO
Credential:
Phone: 843-887-3274