Provider Demographics
NPI:1124124185
Name:SKYLYN WELLNESS CENTER, INC.
Entity type:Organization
Organization Name:SKYLYN WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:V
Authorized Official - Last Name:DAWIDOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-583-8308
Mailing Address - Street 1:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:DRAYTON
Mailing Address - State:SC
Mailing Address - Zip Code:29333-0173
Mailing Address - Country:US
Mailing Address - Phone:864-583-8308
Mailing Address - Fax:864-583-8358
Practice Address - Street 1:1770 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1045
Practice Address - Country:US
Practice Address - Phone:864-583-8308
Practice Address - Fax:864-583-8358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2495111N00000X
207Q00000X
SC3647367500000X
SC14638208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH324Medicaid
SCU81684Medicare UPIN
SCU816840281Medicare ID - Type Unspecified