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General NPI Number Information
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NPI Number | 1003614900
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Entity Type | Organization
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Legal Business Name | AGE WELL SC LLC
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 468 OLD CHEROKEE RD
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City | LEXINGTON
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State | SC
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Zip | 29072-9031
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Country | US
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Telephone | 803-646-0126
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Fax |
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Provider Business Mailing Address
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Address Line | 468 OLD CHEROKEE RD
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City | LEXINGTON
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State | SC
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Zip | 29072-9031
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | TJUANA SEIDL
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Credential | OWNER
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Telephone | 803-646-0126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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