Basic Information
| Provider Information | |||||||||
| NPI: | 1619427697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLMORE OF TEGA CAY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3530 TORINGDON WAY | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042461620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 WELLMORE DR | ||||||||
| Address2: | |||||||||
| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297080124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046120363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 06/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7042461620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | NCF-0988 | SC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.