Healthcare Provider Details

I. General information

NPI: 1851888978
Provider Name (Legal Business Name): MRS. THELISA Y SULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THELISA SULTON MEDICAL ASSISTANT

II. Dates (important events)

Enumeration Date: 04/14/2018
Last Update Date: 02/02/2020
Certification Date: 02/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COLUMBIA MALL BLVD STE 189
COLUMBIA SC
29223-7550
US

IV. Provider business mailing address

201 COLUMBIA MALL BLVD STE 189
COLUMBIA SC
29223-7550
US

V. Phone/Fax

Practice location:
  • Phone: 803-602-5570
  • Fax: 888-958-0279
Mailing address:
  • Phone: 803-602-5570
  • Fax: 888-958-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number2018-46169-45207
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number2018-46169-45207
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number2018-46169-45207
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: