Healthcare Provider Details

I. General information

NPI: 1033672233
Provider Name (Legal Business Name): WELLBORN UPSTATE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2019
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 N PLEASANTBURG DR STE C
GREENVILLE SC
29607-1600
US

IV. Provider business mailing address

1955 DRAYTON RD UNIT 832
DRAYTON SC
29333-5030
US

V. Phone/Fax

Practice location:
  • Phone: 864-583-5831
  • Fax: 888-340-7874
Mailing address:
  • Phone: 909-575-7323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER STEWART
Title or Position: OWNER, LM
Credential: IBCLC, CPM, LM
Phone: 909-575-7323