Provider Demographics
NPI:1578636742
Name:WILSON, TRACY D (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:D
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 1:8004 ABBEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2806
Mailing Address - Country:US
Mailing Address - Phone:806-722-3533
Mailing Address - Fax:806-687-6895
Practice Address - Street 1:8004 ABBEVILLE AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2806
Practice Address - Country:US
Practice Address - Phone:806-722-3533
Practice Address - Fax:806-687-6895
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C9385Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDERNUMBER
TX00741XMedicare ID - Type UnspecifiedGROUP NUMBER