Healthcare Provider Details

I. General information

NPI: 1710844246
Provider Name (Legal Business Name): JUSTIN WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 N HIGHWAY 52 STE 98
MONCKS CORNER SC
29461-3159
US

IV. Provider business mailing address

222 OAK PARK ST
SUMMERVILLE SC
29486-8260
US

V. Phone/Fax

Practice location:
  • Phone: 843-809-5290
  • Fax:
Mailing address:
  • Phone: 912-574-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4907
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: