Provider Demographics
NPI:1275692386
Name:WILSON CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:WILSON CHIROPRACTIC CLINIC
Other - Org Name:BRAMBLETON COMMONS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:KENDALL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-776-0101
Mailing Address - Street 1:PO BOX 20382
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0039
Mailing Address - Country:US
Mailing Address - Phone:540-776-0101
Mailing Address - Fax:540-776-7873
Practice Address - Street 1:3390 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-776-0101
Practice Address - Fax:540-776-7873
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR HOWARD K WILSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU31890Medicare UPIN