Healthcare Provider Details

I. General information

NPI: 1346888948
Provider Name (Legal Business Name): KTP WELLNESS SOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COLUMBIA MALL BLVD STE 189
COLUMBIA SC
29223-7550
US

IV. Provider business mailing address

201 COLUMBIA MALL BLVD STE 189
COLUMBIA SC
29223-7550
US

V. Phone/Fax

Practice location:
  • Phone: 803-404-7418
  • Fax: 888-958-0279
Mailing address:
  • Phone: 803-404-7418
  • Fax: 888-958-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. THELISA Y SULTON
Title or Position: OWNER
Credential: NP
Phone: 803-404-7418