Healthcare Provider Details

I. General information

NPI: 1760807507
Provider Name (Legal Business Name): SYLVESTA COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 SAVANNAH HWY STE J
CHARLESTON SC
29414-5311
US

IV. Provider business mailing address

1643-B SAVANNAH HWY BOX 370
CHARLESTON SC
29407
US

V. Phone/Fax

Practice location:
  • Phone: 843-324-0962
  • Fax:
Mailing address:
  • Phone: 843-324-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberB0003059
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: