Provider Demographics
NPI:1487800694
Name:WILSONGROUP, LLC
Entity type:Organization
Organization Name:WILSONGROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLY
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, OTR/L
Authorized Official - Phone:803-608-2044
Mailing Address - Street 1:135 GARDEN BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7617
Mailing Address - Country:US
Mailing Address - Phone:803-608-2044
Mailing Address - Fax:
Practice Address - Street 1:135 GARDEN BROOKE DR
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7617
Practice Address - Country:US
Practice Address - Phone:803-608-2044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1427171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty