Provider Demographics
NPI:1689857450
Name:WILSON PROSTHETICS CLINIC, LLC
Entity Type:Organization
Organization Name:WILSON PROSTHETICS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO-LPO-FAAOP
Authorized Official - Phone:281-403-0107
Mailing Address - Street 1:2711 CARTWRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2602
Mailing Address - Country:US
Mailing Address - Phone:281-403-0107
Mailing Address - Fax:281-403-0113
Practice Address - Street 1:2711 CARTWRIGHT RD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2602
Practice Address - Country:US
Practice Address - Phone:281-403-0107
Practice Address - Fax:281-403-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101123335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXZ05085353Medicaid
6062710001Medicare NSC