Provider Demographics
NPI:1578915401
Name:BIOSPINE HEALTH AND WELNESS, LLC
Entity Type:Organization
Organization Name:BIOSPINE HEALTH AND WELNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUCKY
Authorized Official - Middle Name:SENTELL
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-940-0687
Mailing Address - Street 1:542 BEN GAUSE RD
Mailing Address - Street 2:
Mailing Address - City:COWARD
Mailing Address - State:SC
Mailing Address - Zip Code:29530-5127
Mailing Address - Country:US
Mailing Address - Phone:843-940-0687
Mailing Address - Fax:
Practice Address - Street 1:542 BEN GAUSE RD
Practice Address - Street 2:
Practice Address - City:COWARD
Practice Address - State:SC
Practice Address - Zip Code:29530-5127
Practice Address - Country:US
Practice Address - Phone:843-940-0687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-03
Last Update Date:2016-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 4099261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service