Provider Demographics
NPI:1083873780
Name:WELLNESSPLUS P A
Entity Type:Organization
Organization Name:WELLNESSPLUS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-571-1020
Mailing Address - Street 1:1001-A PHYSICIANS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5746
Mailing Address - Country:US
Mailing Address - Phone:843-571-1020
Mailing Address - Fax:843-573-0788
Practice Address - Street 1:1001 - A PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5746
Practice Address - Country:US
Practice Address - Phone:843-571-1020
Practice Address - Fax:843-573-0788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1009111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4010Medicare PIN