Provider Demographics
NPI:1407342116
Name:THRIVE ESSENTIAL WELLNESS, INC.
Entity Type:Organization
Organization Name:THRIVE ESSENTIAL WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C, VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:D
Authorized Official - Last Name:TALLENT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:843-251-6688
Mailing Address - Street 1:1511 9TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4126
Mailing Address - Country:US
Mailing Address - Phone:843-488-1894
Mailing Address - Fax:843-488-2786
Practice Address - Street 1:1511 9TH AVE STE A
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4126
Practice Address - Country:US
Practice Address - Phone:843-488-1894
Practice Address - Fax:843-488-2786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1942532023Medicaid
SC1942532023OtherBC/BS
SC1245535574OtherBC/BS
SC1982716586OtherBC/BS
SC1245535574Medicaid
SC1982716585OtherBC/BS
SC1982716585Medicaid