Provider Demographics
NPI:1659121614
Name:SOUTHERN CHARM HEALTH & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:SOUTHERN CHARM HEALTH & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:803-577-6026
Mailing Address - Street 1:114 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-2442
Mailing Address - Country:US
Mailing Address - Phone:803-286-7555
Mailing Address - Fax:989-214-7326
Practice Address - Street 1:114 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2442
Practice Address - Country:US
Practice Address - Phone:803-286-7555
Practice Address - Fax:989-214-7326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC22378OtherSC APRN
SC22N33N45OtherCSL
SCNP5853Medicaid
SCSCL353K651OtherSC MCR