Healthcare Provider Details

I. General information

NPI: 1275033870
Provider Name (Legal Business Name): LAY-UP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 TEAKWOOD DR
DALZELL SC
29040-9652
US

IV. Provider business mailing address

5640 TEAKWOOD DR
DALZELL SC
29040-9652
US

V. Phone/Fax

Practice location:
  • Phone: 803-236-2313
  • Fax:
Mailing address:
  • Phone: 803-236-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MARK SHAW
Title or Position: EXECUTIVE DIRECTOR
Credential: LMSW
Phone: 803-236-2313