Healthcare Provider Details

I. General information

NPI: 1578033965
Provider Name (Legal Business Name): ELITE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 GROCE RD
LYMAN SC
29365-1631
US

IV. Provider business mailing address

12 GROCE RD
LYMAN SC
29365-1631
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-1345
  • Fax: 864-439-1346
Mailing address:
  • Phone: 864-439-1345
  • Fax: 864-439-1346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN PRIME
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 704-473-4653