Healthcare Provider Details

I. General information

NPI: 1710403720
Provider Name (Legal Business Name): MRS. TWILA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5741 D IMBODEN STREET
COLUMBIA SC
29206
US

IV. Provider business mailing address

5741 IMBODEN ST APT D
COLUMBIA SC
29206-5717
US

V. Phone/Fax

Practice location:
  • Phone: 734-288-6644
  • Fax: 803-708-0112
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: