MEDICARE: WICKISER REHAB & WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD14473	SC

General Provider Information

NPI Number	:	1053740852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICKISER REHAB & WELLNESS LLC

Provider Business Mailing Address
First Line	:	3618 E RIVER ST
Second Line	:
City	:	ANDERSON
State	:	SC
Zip	:	29621-7334
Country	:	US
Telephone Number	:	864-224-0246
Fax Number	:	864-224-2524

Provider Business Practice Location Address
First Line	:	3618 E RIVER ST
Second Line	:
City	:	ANDERSON
State	:	SC
Zip	:	29621-7334
Country	:	US
Telephone Number	:	864-224-0246
Fax Number	:	864-224-2524

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	CLIFTON W WICKISER
Credential	:	D.C.
Telephone Number	:	864-224-0246

Provider Enumeration Date	:	11/02/2013
Last Update Date	:	05/22/2024

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