Healthcare Provider Details

I. General information

NPI: 1366568594
Provider Name (Legal Business Name): ST JAMES HEALTH AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 N FRASER ST
GEORGETOWN SC
29440-3260
US

IV. Provider business mailing address

PO BOX 608
MC CLELLANVILLE SC
29458-0608
US

V. Phone/Fax

Practice location:
  • Phone: 843-436-1333
  • Fax: 843-436-1335
Mailing address:
  • Phone: 843-887-3274
  • Fax: 843-887-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number37759
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SANDRA GILLIARD
Title or Position: CEO
Credential:
Phone: 843-887-3274