Provider Demographics
NPI:1538489117
Name:WILSON, LILLIAN JUNE
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:JUNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 W WESMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1987
Mailing Address - Country:US
Mailing Address - Phone:803-905-8047
Mailing Address - Fax:803-905-8025
Practice Address - Street 1:385 W WESMARK BLVD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1987
Practice Address - Country:US
Practice Address - Phone:803-905-8047
Practice Address - Fax:803-905-8025
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC797156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician