Healthcare Provider Details

I. General information

NPI: 1285305797
Provider Name (Legal Business Name): RACHEL L WILSON-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120A E 5TH NORTH ST
SUMMERVILLE SC
29483-6822
US

IV. Provider business mailing address

120A E 5TH NORTH ST
SUMMERVILLE SC
29483-6822
US

V. Phone/Fax

Practice location:
  • Phone: 843-934-1968
  • Fax: 888-298-0519
Mailing address:
  • Phone: 843-934-1968
  • Fax: 888-298-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberRBT-20-149545
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: