=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649896614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY-ELYSE WHELESS EDGAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2020
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 BROCKMAN MCCLIMON RD
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29651-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-989-1432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 CARRIAGE HILL RD
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-5281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-810-7291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 436
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------