Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1074 | SC |
NPI | 1144600107 |
---|---|
Provider Name | Mr. Wilbur Carlyle Ardis III |
First Address | Sumter, SC 29154 |
Second Address | Sumter, SC 29154-7203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2015 |
Last Update Date | 04/06/2015 |