MEDICARE: LOWCOUNTRY WELLNESS CENTER LLC

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	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639604929	OTHER	SC	NPI

General Provider Information

NPI Number	:	1639604929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOWCOUNTRY WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	1565 SAM RITTENBERG BLVD STE 201
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-4138
Country	:	US
Telephone Number	:	843-793-1353
Fax Number	:	843-818-4172

Provider Business Practice Location Address
First Line	:	1565 SAM RITTENBERG BLVD STE 201
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-4138
Country	:	US
Telephone Number	:	843-793-1353
Fax Number	:	843-818-4172

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. PENELOPE LYNN VACHON
Credential	:	APRN
Telephone Number	:	843-793-1353

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	07/28/2025

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