Healthcare Provider Details

I. General information

NPI: 1386134435
Provider Name (Legal Business Name): WELLSPRING HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BLANDING ST STE 4
COLUMBIA SC
29201-2922
US

IV. Provider business mailing address

PO BOX 25271
COLUMBIA SC
29224-5271
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34709
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number34709
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number34709
License Number StateSC

VIII. Authorized Official

Name: JOSNELDAVMATUS FAIIVAE
Title or Position: DIRECTOR
Credential: MD
Phone: 803-760-3306