Provider Demographics
NPI:1225701048
Name:WILSON, EMANUEL DWAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:DWAYNE
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 1:6349 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2707
Mailing Address - Country:US
Mailing Address - Phone:904-400-8258
Mailing Address - Fax:
Practice Address - Street 1:6349 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2707
Practice Address - Country:US
Practice Address - Phone:904-400-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13648111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOP279Medicaid