MEDICARE: WELVISTA

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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386727188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELVISTA

Provider Business Mailing Address
First Line	:	PO BOX 767
Second Line	:
City	:	SUMMERTON
State	:	SC
Zip	:	29148-0767
Country	:	US
Telephone Number	:	803-478-6277
Fax Number	:	803-478-6284

Provider Business Practice Location Address
First Line	:	9077 ALEX HARVIN HWY
Second Line	:
City	:	SUMMERTON
State	:	SC
Zip	:	29148-9803
Country	:	US
Telephone Number	:	803-478-6277
Fax Number	:	803-478-6284

Authorized Official
Title or Position	:	OPERATIONS DIRECTOR
Name	:	MRS. GEORGIA BENNETT FAMULINER
Credential	:
Telephone Number	:	803-584-4803

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	09/20/2017

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Directions to “WELVISTA ” Practice Location

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