Healthcare Provider Details

I. General information

NPI: 1679250146
Provider Name (Legal Business Name): WELSCARE OF SOUTH CAROLINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 LOVETT DR
GREENVILLE SC
29607-6510
US

IV. Provider business mailing address

1250 E 3900 S STE 440
SALT LAKE CITY UT
84124-1349
US

V. Phone/Fax

Practice location:
  • Phone: 801-869-4100
  • Fax: 208-869-4119
Mailing address:
  • Phone: 801-869-4100
  • Fax: 801-869-4119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRAD LILJENQUIST
Title or Position: OWNER
Credential:
Phone: 801-420-2516