| Age Well SC LLC | |
|
468 Old Cherokee Rd Lexington SC 29072-9031 | |
| (803) 646-0126 | |
| Not Available |
| Full Name | Age Well SC LLC |
|---|---|
| Speciality | Clinic/Center |
| Location | 468 Old Cherokee Rd, Lexington, South Carolina |
| Authorized Official Name and Position | Tjuana Seidl (DIRECTOR) |
| Authorized Official Contact | 8036460126 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Age Well SC LLC 468 Old Cherokee Rd Lexington SC 29072-9031 | Age Well SC LLC 468 Old Cherokee Rd Lexington SC 29072-9031 Ph: (803) 646-0126 |
| NPI Number | 1003614900 |
|---|---|
| Provider Enumeration Date | 03/05/2025 |
| Last Update Date | 03/05/2025 |
| Certification Date | 03/05/2025 |
| Medicare PECOS PAC ID | 4981127719 |
|---|---|
| Medicare Enrollment ID | O20250402000425 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003614900 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | () | Primary |
| 363AM0700X | Physician Assistant - Medical | () | Secondary |
| Provider Name | Tjuana Faith Durden Seidl |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1912378290 PECOS PAC ID: 9739480161 Enrollment ID: I20151209000618 |
| Provider Name | Ryan Wayne Seidl |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1821599143 PECOS PAC ID: 9032472188 Enrollment ID: I20180424001574 |
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