MEDICARE: ITRUST WELLNESS GROUP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	20465	SC

General Provider Information

NPI Number	:	1629517222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITRUST WELLNESS GROUP

Provider Business Mailing Address
First Line	:	125 COMMONS WAY
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-3850
Country	:	US
Telephone Number	:	864-520-2020
Fax Number	:	864-640-4400

Provider Business Practice Location Address
First Line	:	149 COMMONS WAY
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-3850
Country	:	US
Telephone Number	:	864-520-2020
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	GRACE KEEL
Credential	:
Telephone Number	:	864-520-5500

Provider Enumeration Date	:	02/15/2017
Last Update Date	:	03/10/2026

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