Provider Demographics
NPI:1497006415
Name:WILSON, RUSTIN CRAIG (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSTIN
Middle Name:CRAIG
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 1:74967 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-7136
Mailing Address - Country:US
Mailing Address - Phone:760-346-5255
Mailing Address - Fax:
Practice Address - Street 1:74967 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-7136
Practice Address - Country:US
Practice Address - Phone:760-346-5255
Practice Address - Fax:760-346-5028
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor