Provider Demographics
NPI:1093773343
Name:WILSON, SEBASTIAN (DC)
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1142
Mailing Address - Country:US
Mailing Address - Phone:517-278-0445
Mailing Address - Fax:517-278-0455
Practice Address - Street 1:273 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1142
Practice Address - Country:US
Practice Address - Phone:517-278-0445
Practice Address - Fax:517-278-0455
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4355154Medicaid
U85411Medicare UPIN
0N31060Medicare ID - Type Unspecified
MI4355154Medicaid
0P56120Medicare PIN