Provider Demographics
NPI:1144600107
Name:ARDIS, WILBUR CARLYLE III
Entity Type:Individual
Prefix:MR
First Name:WILBUR
Middle Name:CARLYLE
Last Name:ARDIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 GIN BRANCH RD.
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154
Mailing Address - Country:US
Mailing Address - Phone:803-450-0384
Mailing Address - Fax:
Practice Address - Street 1:2118 GIN BRANCH RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-7203
Practice Address - Country:US
Practice Address - Phone:803-450-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1074156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician