Provider Demographics
NPI:1043804388
Name:CAROLINA HEALTH AND WELLNESS SERVICES, LLC
Entity Type:Organization
Organization Name:CAROLINA HEALTH AND WELLNESS SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:DEVOLLD
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:843-996-4908
Mailing Address - Street 1:2754 MAYBANK HWY STE B
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-4809
Mailing Address - Country:US
Mailing Address - Phone:843-996-4908
Mailing Address - Fax:843-962-5450
Practice Address - Street 1:2754 MAYBANK HWY STE B
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-4809
Practice Address - Country:US
Practice Address - Phone:843-996-4908
Practice Address - Fax:843-962-5450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC406340Medicaid