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General NPI Number Information
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NPI Number | 1528428299
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Entity Type | Organization
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Legal Business Name | SC-PREMIER WELLNESS CARE
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Dates
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Enumeration Date | 02/24/2016
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Last Update Date | 06/01/2016
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Provider Practice Location Address
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Address Line | 400 PENDLETON RD
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City | CLEMSON
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State | SC
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Zip | 29631-2211
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Country | US
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Telephone | 225-620-6222
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Fax | 864-722-5319
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Provider Business Mailing Address
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Address Line | 400 PENDLETON RD
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City | CLEMSON
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State | SC
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Zip | 29631-2211
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Country | US
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Telephone | 864-722-5315
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Fax | 864-722-5319
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Authorized Official
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Title or Position | CEO
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Name | JACQUE SHADLE
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Credential |
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Telephone | 225-445-0038
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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 |
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License Number State |
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