Healthcare Provider Details

I. General information

NPI: 1861808891
Provider Name (Legal Business Name): WALTERBORO WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110B N MEMORIAL AVE
WALTERBORO SC
29488-3908
US

IV. Provider business mailing address

3741 TIDELAND DR
JOHNS ISLAND SC
29455-7456
US

V. Phone/Fax

Practice location:
  • Phone: 843-782-4111
  • Fax: 843-766-7798
Mailing address:
  • Phone: 843-425-4694
  • Fax: 843-766-7798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number23765
License Number StateSC

VIII. Authorized Official

Name: KAREN LUCKIE
Title or Position: OFFICE MANAGER
Credential:
Phone: 843-571-3100