MEDICARE: KIM P WESELAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	3981	SC

General Provider Information

NPI Number	:	1285769323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM P WESELAK

Provider Business Mailing Address
First Line	:	2925 CARRIAGE ROW LN UNIT 120
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-2104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3803 PALMETTO DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5944
Country	:	US
Telephone Number	:	843-455-7505
Fax Number	:	866-668-9946

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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Directions to “ KIM P WESELAK ” Practice Location

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