Provider Demographics
NPI:1558559690
Name:WILSON, TERRY WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:TERRY
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 1:24835 LA PALMA AVE STE D
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-5532
Mailing Address - Country:US
Mailing Address - Phone:714-692-1771
Mailing Address - Fax:714-692-8620
Practice Address - Street 1:24835 LA PALMA AVE STE D
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-5532
Practice Address - Country:US
Practice Address - Phone:714-692-1771
Practice Address - Fax:714-692-8620
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19650111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC19650Medicare PIN