Provider Demographics
NPI:1841447612
Name:SOUTH CAROLINA BACK PAIN & WELLNESS CENTER
Entity type:Organization
Organization Name:SOUTH CAROLINA BACK PAIN & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-488-0410
Mailing Address - Street 1:PO BOX 2068
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29342-2068
Mailing Address - Country:US
Mailing Address - Phone:864-488-0410
Mailing Address - Fax:864-488-2216
Practice Address - Street 1:303 W BIRNIE ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2307
Practice Address - Country:US
Practice Address - Phone:864-488-0410
Practice Address - Fax:864-488-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3226111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH3226Medicaid
SCCH3226Medicaid
SCAA17729086Medicare UPIN