Healthcare Provider Details

I. General information

NPI: 1649965286
Provider Name (Legal Business Name): WYLD LILLIES CROWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2763 TOBACCO RD STE E
HEPHZIBAH GA
30815-7051
US

IV. Provider business mailing address

2714 DEEN AVE
AUGUSTA GA
30906-3232
US

V. Phone/Fax

Practice location:
  • Phone: 706-726-5406
  • Fax:
Mailing address:
  • Phone: 706-726-5406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM JENNINGS
Title or Position: OWNER
Credential:
Phone: 706-726-5406