Provider Demographics
NPI:1518073741
Name:WILSON, VON WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:VON
Middle Name:WAYNE
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:PO BOX 880640
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80488-0640
Mailing Address - Country:US
Mailing Address - Phone:970-879-8040
Mailing Address - Fax:970-879-8041
Practice Address - Street 1:1125 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487
Practice Address - Country:US
Practice Address - Phone:970-879-8040
Practice Address - Fax:970-879-8041
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO502858Medicare ID - Type Unspecified