Provider Demographics
NPI:1710690912
Name:ENVISION WELLNESS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ENVISION WELLNESS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-256-0101
Mailing Address - Street 1:4100 N MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5800
Mailing Address - Country:US
Mailing Address - Phone:803-256-0101
Mailing Address - Fax:800-854-3497
Practice Address - Street 1:4100 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-256-0101
Practice Address - Fax:800-854-3497
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENVISION WELLNESS MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC0151Medicaid