Healthcare Provider Details

I. General information

NPI: 1003614900
Provider Name (Legal Business Name): AGE WELL SC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 OLD CHEROKEE RD
LEXINGTON SC
29072-9031
US

IV. Provider business mailing address

468 OLD CHEROKEE RD
LEXINGTON SC
29072-9031
US

V. Phone/Fax

Practice location:
  • Phone: 803-646-0126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TJUANA SEIDL
Title or Position: DIRECTOR
Credential: OWNER
Phone: 803-646-0126