Provider Demographics
NPI:1578088993
Name:JIMMY L. WILSON, INC
Entity Type:Organization
Organization Name:JIMMY L. WILSON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HIROKO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIMODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-497-8446
Mailing Address - Street 1:650 MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-6862
Mailing Address - Country:US
Mailing Address - Phone:407-497-8446
Mailing Address - Fax:
Practice Address - Street 1:14 OLD GROVE LN
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-7947
Practice Address - Country:US
Practice Address - Phone:407-497-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty