Provider Demographics
NPI:1982144606
Name:COMMUNITY WELLNESS GROUP LLC
Entity type:Organization
Organization Name:COMMUNITY WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:803-586-1752
Mailing Address - Street 1:7356 GARNERS FERRY RD SUITE 130
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-2178
Mailing Address - Country:US
Mailing Address - Phone:803-586-1752
Mailing Address - Fax:877-995-5934
Practice Address - Street 1:2430 ATLAS RD STE 1
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-3625
Practice Address - Country:US
Practice Address - Phone:803-586-1752
Practice Address - Fax:877-995-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8968Medicaid