Healthcare Provider Details

I. General information

NPI: 1386727188
Provider Name (Legal Business Name): WELVISTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9077 ALEX HARVIN HWY
SUMMERTON SC
29148-9803
US

IV. Provider business mailing address

PO BOX 767
SUMMERTON SC
29148-0767
US

V. Phone/Fax

Practice location:
  • Phone: 803-478-6277
  • Fax: 803-478-6284
Mailing address:
  • Phone: 803-478-6277
  • Fax: 803-478-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. GEORGIA BENNETT FAMULINER
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 803-584-4803