Provider Demographics
NPI:1295214088
Name:THE WELL LLC
Entity Type:Organization
Organization Name:THE WELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MMP, RYT-200
Authorized Official - Phone:803-816-2716
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:BALLENTINE
Mailing Address - State:SC
Mailing Address - Zip Code:29002-0253
Mailing Address - Country:US
Mailing Address - Phone:803-816-2716
Mailing Address - Fax:
Practice Address - Street 1:1720 DUTCH FORK RD.
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:806-816-2716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty