Provider Demographics
NPI:1528428299
Name:SC-PREMIER WELLNESS CARE
Entity type:Organization
Organization Name:SC-PREMIER WELLNESS CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-445-0038
Mailing Address - Street 1:400 PENDLETON RD
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2211
Mailing Address - Country:US
Mailing Address - Phone:864-722-5315
Mailing Address - Fax:864-722-5319
Practice Address - Street 1:400 PENDLETON RD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2211
Practice Address - Country:US
Practice Address - Phone:225-620-6222
Practice Address - Fax:864-722-5319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty