Provider Demographics
NPI:1174003180
Name:CARTER, WILTON TODD
Entity Type:Individual
Prefix:
First Name:WILTON
Middle Name:TODD
Last Name:CARTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 OAK CLIFF ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-4480
Mailing Address - Country:US
Mailing Address - Phone:912-278-1479
Mailing Address - Fax:
Practice Address - Street 1:101 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8852
Practice Address - Country:US
Practice Address - Phone:912-278-1479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007086225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist