Healthcare Provider Details

I. General information

NPI: 1326074576
Provider Name (Legal Business Name): WELL FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1483 TOBIAS GADSON BLVD SUITE 102
CHARLESTON SC
29407-8702
US

IV. Provider business mailing address

1483 TOBIAS GADSON BLVD SUITE 102
CHARLESTON SC
29407-8702
US

V. Phone/Fax

Practice location:
  • Phone: 843-766-6229
  • Fax: 843-766-2315
Mailing address:
  • Phone: 843-766-6229
  • Fax: 843-766-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number19704
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19704
License Number StateSC

VIII. Authorized Official

Name: MS. LORI ANN COX
Title or Position: PRACTICE MANAGER
Credential:
Phone: 843-766-6229