Provider Demographics
NPI:1053740852
Name:WICKISER REHAB & WELLNESS LLC
Entity type:Organization
Organization Name:WICKISER REHAB & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WICKISER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-224-0246
Mailing Address - Street 1:3618 E RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-7334
Mailing Address - Country:US
Mailing Address - Phone:864-224-0246
Mailing Address - Fax:864-224-2524
Practice Address - Street 1:3618 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7334
Practice Address - Country:US
Practice Address - Phone:864-224-0246
Practice Address - Fax:864-224-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD14473207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty