Healthcare Provider Details

I. General information

NPI: 1255733432
Provider Name (Legal Business Name): MEREDITH WENTZEL IBCLC, LMBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 GARLINGTON RD STE D9
GREENVILLE SC
29615-4610
US

IV. Provider business mailing address

105 MEADOW BLOSSOM WAY
SIMPSONVILLE SC
29681-6588
US

V. Phone/Fax

Practice location:
  • Phone: 864-757-4951
  • Fax:
Mailing address:
  • Phone: 864-497-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4807
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number79127
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: