Organization
TAMARA WILLARD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TAMARA WILLARD (OWNER)
(843) 360-9491
Entity
Organization
Contact information
Practice address
4221 MAYFAIR ST, MYRTLE BEACH, SC 29577-5757
(843) 360-9491
Mailing address
4221 MAYFAIR ST, MYRTLE BEACH, SC 29577-5757
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
4859
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PC1117
—
SC
Enumeration date
04/21/2017
Last updated
04/21/2017
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