Provider Demographics
NPI:1366568594
Name:ST JAMES HEALTH AND WELLNESS INC
Entity type:Organization
Organization Name:ST JAMES HEALTH AND WELLNESS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-887-3274
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:MC CLELLANVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29458-0608
Mailing Address - Country:US
Mailing Address - Phone:843-887-3274
Mailing Address - Fax:843-887-3929
Practice Address - Street 1:422 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3260
Practice Address - Country:US
Practice Address - Phone:843-436-1333
Practice Address - Fax:843-436-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC377592080A0000X
261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC377596Medicaid