Provider Demographics
NPI:1346888948
Name:KTP WELLNESS SOLUTION LLC
Entity Type:Organization
Organization Name:KTP WELLNESS SOLUTION LLC
Other - Org Name:BIO-WORX WELLNESS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THELISA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:SULTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:803-404-7418
Mailing Address - Street 1:201 COLUMBIA MALL BLVD STE 189
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7550
Mailing Address - Country:US
Mailing Address - Phone:803-404-7418
Mailing Address - Fax:888-958-0279
Practice Address - Street 1:201 COLUMBIA MALL BLVD STE 189
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-7550
Practice Address - Country:US
Practice Address - Phone:803-404-7418
Practice Address - Fax:888-958-0279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12345678OtherMULTI- SPECIALITY CLINIC