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General NPI Number Information
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NPI Number | 1295214088
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Entity Type | Organization
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Legal Business Name | THE WELL LLC
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Dates
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Enumeration Date | 08/13/2018
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Last Update Date | 07/14/2019
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Provider Practice Location Address
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Address Line | 1720 DUTCH FORK RD.
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City | IRMO
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State | SC
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Zip | 29063
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Country | US
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Telephone | 806-816-2716
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 253
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City | BALLENTINE
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State | SC
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Zip | 29002-0253
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Country | US
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Telephone | 803-816-2716
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MRS. SHAWN TAYLOR MOORE
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Credential | LMT, MMP, RYT-200
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Telephone | 803-816-2716
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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