Provider Demographics
NPI:1336992601
Name:FORT MILL SENIOR WELLNESS LLC
Entity Type:Organization
Organization Name:FORT MILL SENIOR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:P
Authorized Official - Last Name:GAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-346-0252
Mailing Address - Street 1:331 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-5384
Mailing Address - Country:US
Mailing Address - Phone:860-346-0252
Mailing Address - Fax:
Practice Address - Street 1:331 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5384
Practice Address - Country:US
Practice Address - Phone:704-438-0687
Practice Address - Fax:844-591-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty