Healthcare Provider Details

I. General information

NPI: 1003924093
Provider Name (Legal Business Name): KENNETH JAAN WENZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 VILLAGE CENTER BLVD STE 150
MYRTLE BEACH SC
29579-6707
US

IV. Provider business mailing address

210 VILLAGE CENTER BLVD STE 150
MYRTLE BEACH SC
29579-6707
US

V. Phone/Fax

Practice location:
  • Phone: 843-353-3460
  • Fax: 843-903-9032
Mailing address:
  • Phone: 843-353-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number17498
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number17498
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: