Provider Demographics
NPI:1760808083
Name:SELF MEDICAL GROUP
Entity Type:Organization
Organization Name:SELF MEDICAL GROUP
Other - Org Name:LIGHT AND LIFE WELLNESS CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-725-4253
Mailing Address - Street 1:104 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3837
Mailing Address - Country:US
Mailing Address - Phone:864-725-7491
Mailing Address - Fax:
Practice Address - Street 1:450 OLD BRICKYARD RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-8681
Practice Address - Country:US
Practice Address - Phone:864-725-7491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine