Healthcare Provider Details

I. General information

NPI: 1487486221
Provider Name (Legal Business Name): TRANSITIONAL WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 KING LEES COURT
LEXINGTON SC
29072
US

IV. Provider business mailing address

955 EAST MAIN STREET SUITE E #6
LEXINGTON SC
29072
US

V. Phone/Fax

Practice location:
  • Phone: 803-239-4660
  • Fax: 803-233-4656
Mailing address:
  • Phone: 803-239-4660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TARA PATRCIA DAVIS
Title or Position: CEO/OWNER
Credential: MSN, FNP-BC
Phone: 757-407-0800