Provider Demographics
NPI:1285922336
Name:ASY ABSOLUTE WELLNESS CLINIC, LLC
Entity type:Organization
Organization Name:ASY ABSOLUTE WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/STAFF
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:803-335-1272
Mailing Address - Street 1:2712 MIDDLEBURG DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2415
Mailing Address - Country:US
Mailing Address - Phone:803-335-1272
Mailing Address - Fax:803-335-1272
Practice Address - Street 1:2712 MIDDLEBURG DR
Practice Address - Street 2:SUITE 206
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2415
Practice Address - Country:US
Practice Address - Phone:803-335-1272
Practice Address - Fax:803-335-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GP5785174400000X
SC22943261QM0855X
SC42D2033880291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5785Medicaid