Provider Demographics
NPI:1144589458
Name:WILSON, ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-0099
Mailing Address - Country:US
Mailing Address - Phone:931-729-4001
Mailing Address - Fax:931-729-4081
Practice Address - Street 1:132A N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033
Practice Address - Country:US
Practice Address - Phone:931-729-4001
Practice Address - Fax:931-729-4081
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2591111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6128617OtherBLUE CROSS BLUE SHIELD OF TENNESSEE
1366957656OtherNPPES - PLLC NPI