MEDICARE: DR. SUZANNE LYNN WILDS D.C.

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	111N00000X	Chiropractor	1900	SC

General Provider Information

NPI Number	:	1679797898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUZANNE LYNN WILDS D.C.

Provider Business Mailing Address
First Line	:	704 RITTER DR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-9019
Country	:	US
Telephone Number	:	843-406-9731
Fax Number	:

Provider Business Practice Location Address
First Line	:	1649 SAVANNAH HWY
Second Line	:	SUITE E
City	:	CHARLESTON
State	:	SC
Zip	:	29407-2232
Country	:	US
Telephone Number	:	843-766-6656
Fax Number	:	843-766-6656

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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