Healthcare Provider Details

I. General information

NPI: 1760903538
Provider Name (Legal Business Name): CANDACE RAQUEL WULFF DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SUNSET DRIVE SURGERY CLINIC
COLUMBIA SC
29203
US

IV. Provider business mailing address

1801 SUNSET DRIVE SURGERY CLINIC
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax: 803-434-4183
Mailing address:
  • Phone: 803-434-6155
  • Fax: 803-434-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL51258
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: