Provider Demographics
NPI:1679250146
Name:WELSCARE OF SOUTH CAROLINA, LLC
Entity type:Organization
Organization Name:WELSCARE OF SOUTH CAROLINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:LILJENQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-420-2516
Mailing Address - Street 1:1250 E 3900 S STE 440
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1349
Mailing Address - Country:US
Mailing Address - Phone:801-869-4100
Mailing Address - Fax:801-869-4119
Practice Address - Street 1:111 LOVETT DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6510
Practice Address - Country:US
Practice Address - Phone:801-869-4100
Practice Address - Fax:208-869-4119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty