Provider Demographics
NPI:1669989901
Name:HEALTHY LIVING WELLNESS AND HEALTHCARE
Entity type:Organization
Organization Name:HEALTHY LIVING WELLNESS AND HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TIERRA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:WIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-617-3226
Mailing Address - Street 1:105 S FRANKLIN DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4364
Mailing Address - Country:US
Mailing Address - Phone:843-617-3226
Mailing Address - Fax:
Practice Address - Street 1:105 S FRANKLIN DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4364
Practice Address - Country:US
Practice Address - Phone:843-617-3226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care