Provider Demographics
NPI:1598156382
Name:WILCOX, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29344 HOOVER RD
Mailing Address - Street 2:STE 206
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3441
Mailing Address - Country:US
Mailing Address - Phone:810-208-9223
Mailing Address - Fax:810-208-9223
Practice Address - Street 1:29344 HOOVER RD
Practice Address - Street 2:STE 206
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3441
Practice Address - Country:US
Practice Address - Phone:810-208-9223
Practice Address - Fax:810-208-9223
Is Sole Proprietor?:No
Enumeration Date:2015-02-14
Last Update Date:2015-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002099172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist