Healthcare Provider Details

I. General information

NPI: 1164090957
Provider Name (Legal Business Name): SVS HYDRATION & WELLNESS LOUNGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 SUNSET BLVD # 1095
WEST COLUMBIA SC
29169-5914
US

IV. Provider business mailing address

1304 SUNSET BLVD # 1095
WEST COLUMBIA SC
29169-5914
US

V. Phone/Fax

Practice location:
  • Phone: 803-594-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VERLISHA GOINS
Title or Position: PROVIDER
Credential:
Phone: 803-594-3300