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General NPI Number Information
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NPI Number | 1992454532
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Entity Type | Organization
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Legal Business Name | BROAD RIVER WELLNESS, LLC
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Dates
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Enumeration Date | 03/21/2022
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 4027 WOODLAWN ST
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City | SHARON
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State | SC
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Zip | 29742-8779
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Country | US
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Telephone | 803-627-0220
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Fax |
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Provider Business Mailing Address
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Address Line | 4027 WOODLAWN ST
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City | SHARON
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State | SC
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Zip | 29742-8779
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Country | US
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Telephone | 803-658-5058
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Fax | 803-658-5035
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Authorized Official
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Title or Position | OWNER
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Name | REBECCA BAKER
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Credential | NP
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Telephone | 803-658-5058
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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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