Basic Information
| Provider Information | |||||||||
| NPI: | 1619532801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILDEWOOD RETIREMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 TORINGDON WAY STE 204 | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042461620 | ||||||||
| FaxNumber: | 7042461621 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 POLO RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292234462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037885115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7048157341 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.