Provider Demographics
NPI:1043832157
Name:ENVISION WELLNESS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ENVISION WELLNESS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYANNA
Authorized Official - Middle Name:SWINTON
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-256-0101
Mailing Address - Street 1:4100 N MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5800
Mailing Address - Country:US
Mailing Address - Phone:803-256-0101
Mailing Address - Fax:800-854-3497
Practice Address - Street 1:4100 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-256-0101
Practice Address - Fax:800-854-3497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty