Provider Demographics
NPI:1548783798
Name:WILSON CHIROPRACTIC WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WILSON CHIROPRACTIC WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-732-1368
Mailing Address - Street 1:9102 SHORT CUT RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-9202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9102 SHORT CUT RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-9202
Practice Address - Country:US
Practice Address - Phone:608-723-6188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38970100Medicaid