Provider Demographics
NPI:1891732335
Name:PWIC OF BENNETTSVILLE
Entity Type:Organization
Organization Name:PWIC OF BENNETTSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-431-9352
Mailing Address - Street 1:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-1066
Mailing Address - Country:US
Mailing Address - Phone:843-431-9352
Mailing Address - Fax:843-431-9901
Practice Address - Street 1:101 NORTHWOOD DR
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2476
Practice Address - Country:US
Practice Address - Phone:843-479-6102
Practice Address - Fax:843-479-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2668Medicaid
SCCH2668Medicaid