Provider Demographics
NPI:1750500567
Name:WILSON, STEVE A
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2262
Mailing Address - Country:US
Mailing Address - Phone:619-280-4570
Mailing Address - Fax:619-280-4571
Practice Address - Street 1:3655 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2262
Practice Address - Country:US
Practice Address - Phone:619-280-4570
Practice Address - Fax:619-280-4571
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 18696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor