Active NPI
Broad River Wellness, LLC
- Family Medicine Physician
- Sharon, SC
National Provider Identifier
1992454532
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- BROAD RIVER WELLNESS, LLC
- Practice address
- 4027 Woodlawn St
Sharon, SC 29742-8779 - Phone
- (803) 627-0220
- NPI assigned
- Mar 21, 2022
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Rebecca Baker, NP
- Title
- Owner
- Phone
- (803) 658-5058
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary |
Addresses
Primary practice location
4027 Woodlawn St
Sharon, SC 29742-8779
Mailing address
4027 Woodlawn St
Sharon, SC 29742-8779
Phone (803) 658-5058
Other practice location 1
602 S Main St
Clover, SC 29710-1426
Phone (803) 658-5058
Electronic endpoints 3
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | Optimantra | Health Information Exchange (HIE) | |
| CONNECT URL | OPTIMANTRA | Health Information Exchange (HIE) | |
| SOAP URL | Optimantra | Health Information Exchange (HIE) |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20220627000153 | SC | Part B Supplier - Clinic/Group Practice | 2567841281 |
Receives reassigned benefits from 3 practitioners Practice locations: Sharon, SC |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 42D2256433 | Broad River Wellness, LLC | Certificate of waiver | Mar 23, 2028 |
National Provider Directory
National Provider DirectoryLocations
602 S Main St
Clover, SC 29710
Phone (803) 658-5058
4027 Woodlawn St
Sharon, SC 29742
Phone (803) 627-0220
Practitioners & affiliated clinicians
Practitioners 3
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1647820800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1718582400000",
"number": "1992454532",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4027 WOODLAWN ST",
"city": "SHARON",
"state": "SC",
"postal_code": "297428779",
"telephone_number": "803-658-5058",
"fax_number": "803-658-5035"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4027 WOODLAWN ST",
"city": "SHARON",
"state": "SC",
"postal_code": "297428779",
"telephone_number": "803-627-0220"
}
],
"practiceLocations": [
{
"address_1": "602 S Main St",
"address_purpose": "LOCATION",
"city": "Clover",
"state": "SC",
"postal_code": "297101426",
"country_code": "US",
"telephone_number": "803-658-5058",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"organization_name": "BROAD RIVER WELLNESS, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2022-03-21",
"last_updated": "2024-06-17",
"certification_date": "2024-06-17",
"status": "A",
"authorized_official_last_name": "BAKER",
"authorized_official_first_name": "REBECCA",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "803-658-5058",
"authorized_official_credential": "NP"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "Optimantra",
"affiliation": "N",
"endpointDescription": "EMR",
"use": "HIE",
"useDescription": "Health Information Exchange (HIE)",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "4027 Woodlawn St",
"city": "Sharon",
"state": "SC",
"country_code": "US",
"postal_code": "297428779",
"country_name": "United States",
"address_type": "DOM"
},
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "OPTIMANTRA",
"affiliation": "N",
"endpointDescription": "EMR",
"use": "HIE",
"useDescription": "Health Information Exchange (HIE)",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "4027 Woodlawn St",
"city": "Sharon",
"state": "SC",
"country_code": "US",
"postal_code": "297428779",
"country_name": "United States",
"address_type": "DOM"
},
{
"endpointType": "SOAP",
"endpointTypeDescription": "SOAP URL",
"endpoint": "Optimantra",
"affiliation": "N",
"endpointDescription": "Optimantra",
"use": "HIE",
"useDescription": "Health Information Exchange (HIE)",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "4027 Woodlawn St",
"city": "Sharon",
"state": "SC",
"country_code": "US",
"postal_code": "297428779",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Sharon, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.