Provider Demographics
NPI:1962772764
Name:INFINITE WELLNESS CENTER
Entity type:Organization
Organization Name:INFINITE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-547-4343
Mailing Address - Street 1:1698 HIGHWAY 160 W STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8034
Mailing Address - Country:US
Mailing Address - Phone:803-547-4343
Mailing Address - Fax:803-547-3914
Practice Address - Street 1:1698 HIGHWAY 160 W STE 200
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8034
Practice Address - Country:US
Practice Address - Phone:803-547-4343
Practice Address - Fax:803-547-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC943207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6712580001Medicare NSC