Provider Demographics
NPI:1497002901
Name:WELLNESS BOUTIQUE LLC
Entity Type:Organization
Organization Name:WELLNESS BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MCHELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:QUAYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-861-2726
Mailing Address - Street 1:PO BOX 1763
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1763
Mailing Address - Country:US
Mailing Address - Phone:843-861-2726
Mailing Address - Fax:
Practice Address - Street 1:107 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4113
Practice Address - Country:US
Practice Address - Phone:843-861-2726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22891207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC28916Medicaid
SCH06257Medicare UPIN