Provider Demographics
NPI:1871362459
Name:UPSTATE WELLNESS CENTER LLC
Entity type:Organization
Organization Name:UPSTATE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN
Authorized Official - Phone:864-940-0523
Mailing Address - Street 1:102 BUFORD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3365
Mailing Address - Country:US
Mailing Address - Phone:864-261-9506
Mailing Address - Fax:
Practice Address - Street 1:102 BUFORD AVE STE A
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3365
Practice Address - Country:US
Practice Address - Phone:864-261-9506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-25
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty