Provider Demographics
NPI:1023527348
Name:WELVISTA
Entity type:Organization
Organization Name:WELVISTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SMILES OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMULINER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:803-584-4803
Mailing Address - Street 1:395 PINE ST E
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944-9617
Mailing Address - Country:US
Mailing Address - Phone:803-300-7028
Mailing Address - Fax:803-584-4806
Practice Address - Street 1:395 PINE ST E
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-9617
Practice Address - Country:US
Practice Address - Phone:803-300-7028
Practice Address - Fax:803-584-4806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty