Provider Demographics
NPI:1831511989
Name:ENVISION WELLNESS MEDICAL GROUP
Entity type:Organization
Organization Name:ENVISION WELLNESS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FELDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-256-0101
Mailing Address - Street 1:2601 READ ST
Mailing Address - Street 2:SUITE I-7
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-7861
Mailing Address - Country:US
Mailing Address - Phone:803-256-0101
Mailing Address - Fax:800-854-3497
Practice Address - Street 1:2601 READ ST
Practice Address - Street 2:SUITE I-7
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-7861
Practice Address - Country:US
Practice Address - Phone:803-256-0101
Practice Address - Fax:800-854-3497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC229432084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC229434Medicaid
SC229434Medicaid