Provider Demographics
NPI:1194015925
Name:WILSON, RICHARD GROVER (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GROVER
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 1:708 LAKE AIR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5772
Mailing Address - Country:US
Mailing Address - Phone:254-741-6122
Mailing Address - Fax:
Practice Address - Street 1:708 LAKE AIR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5772
Practice Address - Country:US
Practice Address - Phone:254-741-6122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor