Provider Demographics
NPI:1033672233
Name:WELLBORN UPSTATE, LLC
Entity Type:Organization
Organization Name:WELLBORN UPSTATE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LM
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:IBCLC, CPM, LM
Authorized Official - Phone:909-575-7323
Mailing Address - Street 1:1955 DRAYTON RD UNIT 832
Mailing Address - Street 2:
Mailing Address - City:DRAYTON
Mailing Address - State:SC
Mailing Address - Zip Code:29333-5030
Mailing Address - Country:US
Mailing Address - Phone:909-575-7323
Mailing Address - Fax:
Practice Address - Street 1:902 N PLEASANTBURG DR STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1600
Practice Address - Country:US
Practice Address - Phone:864-583-5831
Practice Address - Fax:888-340-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-13
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245520774OtherNPPES
1245520774OtherNPPES