Healthcare Provider Details

I. General information

NPI: 1285922336
Provider Name (Legal Business Name): ASY ABSOLUTE WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 MIDDLEBURG DR SUITE 206
COLUMBIA SC
29204-2415
US

IV. Provider business mailing address

2712 MIDDLEBURG DR SUITE 206
COLUMBIA SC
29204-2415
US

V. Phone/Fax

Practice location:
  • Phone: 803-335-1272
  • Fax: 803-335-1272
Mailing address:
  • Phone: 803-335-1272
  • Fax: 803-335-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberGP5785
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number22943
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number42D2033880
License Number StateSC

VIII. Authorized Official

Name: MR. CHRISTOPHER YOUNG
Title or Position: PARTNER/STAFF
Credential: M.E.D
Phone: 803-335-1272