Healthcare Provider Details

I. General information

NPI: 1659121614
Provider Name (Legal Business Name): SOUTHERN CHARM MEDICAL AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S PEARL ST STE B
PAGELAND SC
29728-2261
US

IV. Provider business mailing address

211 S PEARL ST STE B
PAGELAND SC
29728-2261
US

V. Phone/Fax

Practice location:
  • Phone: 843-675-5070
  • Fax: 989-214-7326
Mailing address:
  • Phone: 843-675-5070
  • Fax: 989-214-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MISS CRYSTAL B CLARK
Title or Position: OWNER/PROVIDER
Credential: FNP-C
Phone: 843-675-5070