Provider Demographics
NPI:1679829840
Name:SEABROOK ISLAND WELLNESS INCORPORATED
Entity Type:Organization
Organization Name:SEABROOK ISLAND WELLNESS INCORPORATED
Other - Org Name:STILL WATERS STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OF ORIENTAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WHITE KURYLA
Authorized Official - Suffix:
Authorized Official - Credentials:OMD
Authorized Official - Phone:843-300-9626
Mailing Address - Street 1:4430 BETSY KERRISON PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-7125
Mailing Address - Country:US
Mailing Address - Phone:843-300-9626
Mailing Address - Fax:
Practice Address - Street 1:164 MARKET ST
Practice Address - Street 2:SUITE 292
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-6948
Practice Address - Country:US
Practice Address - Phone:843-300-9626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1913173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173C00000XOther Service ProvidersReflexologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherBLUE CROSS BLUE SHIELD