Provider Demographics
NPI:1386727188
Name:WELVISTA
Entity type:Organization
Organization Name:WELVISTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:FAMULINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-584-4803
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-0767
Mailing Address - Country:US
Mailing Address - Phone:803-478-6277
Mailing Address - Fax:803-478-6284
Practice Address - Street 1:9077 ALEX HARVIN HWY
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148-9803
Practice Address - Country:US
Practice Address - Phone:803-478-6277
Practice Address - Fax:803-478-6284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9502Medicaid