Provider Demographics
NPI:1679538565
Name:WILSON, THOMAS CHARLES (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHARLES
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 1:213 STATE ST W
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3005
Mailing Address - Country:US
Mailing Address - Phone:218-847-4366
Mailing Address - Fax:218-847-1838
Practice Address - Street 1:213 STATE ST W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3005
Practice Address - Country:US
Practice Address - Phone:218-847-4366
Practice Address - Fax:218-847-1838
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN001629111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN49403WIOtherBLUE CROSS/BLUE SHIELD
MN972327700Medicaid
MN410144OtherCHIROPRACTIC CARE OF MN
MN972327700Medicaid
MN350037647Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MN350001626Medicare ID - Type Unspecified