Provider Demographics
NPI:1407994692
Name:WILSON PHYSICAL THERAPY & WELLNESS
Entity Type:Organization
Organization Name:WILSON PHYSICAL THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:931-381-8444
Mailing Address - Street 1:1412 TROTWOOD AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4968
Mailing Address - Country:US
Mailing Address - Phone:931-381-8444
Mailing Address - Fax:
Practice Address - Street 1:1412 TROTWOOD AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4968
Practice Address - Country:US
Practice Address - Phone:931-381-8444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1648261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN003144510OtherBLUE CROSS BLUE SHIELD
TN0446647OtherTENNCARE
TN003144510OtherBLUE CROSS BLUE SHIELD
TN446647Medicare ID - Type Unspecified