Provider Demographics
NPI:1841442076
Name:WILDERMUTH, VICKY
Entity type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:VICKY
Other - Middle Name:
Other - Last Name:WILDERMUTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1470 BEN SAWYER BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4593
Mailing Address - Country:US
Mailing Address - Phone:843-323-5560
Mailing Address - Fax:843-388-5204
Practice Address - Street 1:829 FRONT ST STE H
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3564
Practice Address - Country:US
Practice Address - Phone:843-323-5560
Practice Address - Fax:843-388-5204
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor