Provider Demographics
NPI:1346854320
Name:WILCO CIVIL, D.O. PLLC
Entity Type:Organization
Organization Name:WILCO CIVIL, D.O. PLLC
Other - Org Name:CIVIL MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:WILCO
Authorized Official - Middle Name:
Authorized Official - Last Name:CIVIL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-403-9096
Mailing Address - Street 1:5230 LAND O LAKES BLVD
Mailing Address - Street 2:#2873
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18598 MILTON KEYNES CT
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-2202
Practice Address - Country:US
Practice Address - Phone:813-403-9096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-07
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No251G00000XAgenciesHospice Care, Community Based
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS16855OtherFLORIDA DEPARTMENT OF HEALTH