Provider Demographics
NPI:1689216863
Name:LIVE FOR WELLNESS JOHNS ISLAND
Entity type:Organization
Organization Name:LIVE FOR WELLNESS JOHNS ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-737-6960
Mailing Address - Street 1:3417 SHELBY RAY CT STE C
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5895
Mailing Address - Country:US
Mailing Address - Phone:843-737-6960
Mailing Address - Fax:843-737-6960
Practice Address - Street 1:1803 CROWNE COMMONS WAY
Practice Address - Street 2:SUITE 1-A
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455
Practice Address - Country:US
Practice Address - Phone:843-737-6960
Practice Address - Fax:843-737-6960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVE FOR WELLNESS CHIROPRACTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-09
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH3757Medicaid
SC1124551064OtherBCBS