Provider Demographics
NPI:1750361986
Name:WOMAN'S WELLNESS CENTER, PC
Entity type:Organization
Organization Name:WOMAN'S WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:NILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-347-4600
Mailing Address - Street 1:2376 CYPRESS CIR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8964
Mailing Address - Country:US
Mailing Address - Phone:843-347-4660
Mailing Address - Fax:843-347-6495
Practice Address - Street 1:2376 CYPRESS CIR
Practice Address - Street 2:SUITE 203
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8964
Practice Address - Country:US
Practice Address - Phone:843-347-4660
Practice Address - Fax:843-347-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13889207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2992Medicaid
SC6811Medicare ID - Type Unspecified