Provider Demographics
NPI:1730803495
Name:CELESTIAL SANCTUARY LLC
Entity type:Organization
Organization Name:CELESTIAL SANCTUARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DELL
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, LM, CPM
Authorized Official - Phone:864-203-5588
Mailing Address - Street 1:501 MEMORIAL DRIVE EXT STE A
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-1123
Mailing Address - Country:US
Mailing Address - Phone:864-203-5588
Mailing Address - Fax:877-243-1872
Practice Address - Street 1:501 MEMORIAL DRIVE EXT STE A
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1123
Practice Address - Country:US
Practice Address - Phone:864-203-5588
Practice Address - Fax:877-243-1872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMW0246Medicaid