Healthcare Provider Details

I. General information

NPI: 1801222377
Provider Name (Legal Business Name): AILENE G CAULDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BROAD ST
MULLINS SC
29574-2532
US

IV. Provider business mailing address

410 N BEAR SWAMP RD
LAKE VIEW SC
29563-5152
US

V. Phone/Fax

Practice location:
  • Phone: 843-464-3740
  • Fax:
Mailing address:
  • Phone: 843-759-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP31486
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: