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General NPI Number Information
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NPI Number | 1013396027
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Entity Type | Organization
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Legal Business Name | FAMILY WELLNESS CENTER OF CHARLESTON
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Dates
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Enumeration Date | 05/22/2015
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Last Update Date | 05/22/2015
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Provider Practice Location Address
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Address Line | 9217 UNIVERSITY BLVD SUITE C1B
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9147
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Country | US
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Telephone | 843-729-8269
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Fax |
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Provider Business Mailing Address
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Address Line | 9217 UNIVERSITY BLVD SUITE C1B
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9147
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Country | US
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Telephone | 843-729-8269
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STANIA DEJESUS
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Credential |
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Telephone | 843-729-8269
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MDO.1175DO
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | LIC-1-15-126877
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License Number State | SC
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