Provider Demographics
NPI:1760807507
Name:COLLINS, SYLVESTA
Entity Type:Individual
Prefix:
First Name:SYLVESTA
Middle Name:
Last Name:COLLINS
Suffix:
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 1:1643-B SAVANNAH HWY
Mailing Address - Street 2:BOX 370
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-324-0962
Mailing Address - Fax:
Practice Address - Street 1:2178 SAVANNAH HWY STE J
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5311
Practice Address - Country:US
Practice Address - Phone:843-324-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCB0003059171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor