Provider Demographics
NPI:1467625889
Name:KEVIN C WILSON ND, PC
Entity Type:Organization
Organization Name:KEVIN C WILSON ND, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-648-0484
Mailing Address - Street 1:328 W MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-3967
Mailing Address - Country:US
Mailing Address - Phone:503-648-0484
Mailing Address - Fax:503-681-9280
Practice Address - Street 1:328 W MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-3967
Practice Address - Country:US
Practice Address - Phone:503-648-0484
Practice Address - Fax:503-681-9280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR546175F00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty