Healthcare Provider Details

I. General information

NPI: 1366909053
Provider Name (Legal Business Name): MARIA REGINA VIDANES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 TRADITIONS WAY
COLUMBIA SC
29229-7426
US

IV. Provider business mailing address

601 TRADITIONS WAY
COLUMBIA SC
29229-7426
US

V. Phone/Fax

Practice location:
  • Phone: 803-708-2795
  • Fax:
Mailing address:
  • Phone: 803-708-2795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95871
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: