Healthcare Provider Details

I. General information

NPI: 1811674088
Provider Name (Legal Business Name): SRJ CREATIVE ENDEAVORS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 CHARLOTTE HWY STE 2
LAKE WYLIE SC
29710-8147
US

IV. Provider business mailing address

2764 PLEASANT RD STE A #10321
FORT MILL SC
29708
US

V. Phone/Fax

Practice location:
  • Phone: 803-820-9185
  • Fax:
Mailing address:
  • Phone: 803-820-9185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JOHNSON
Title or Position: OWNER
Credential: LMT
Phone: 803-820-9185