Provider Demographics
NPI:1679797898
Name:WILDS, SUZANNE LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:LYNN
Last Name:WILDS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 RITTER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-9019
Mailing Address - Country:US
Mailing Address - Phone:843-406-9731
Mailing Address - Fax:
Practice Address - Street 1:1649 SAVANNAH HWY
Practice Address - Street 2:SUITE E
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-2232
Practice Address - Country:US
Practice Address - Phone:843-766-6656
Practice Address - Fax:843-766-6656
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor