Provider Demographics
NPI:1851591150
Name:WILSON PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WILSON PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:701-526-3498
Mailing Address - Street 1:3101 BROADWAY N
Mailing Address - Street 2:SUITE C
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1485
Mailing Address - Country:US
Mailing Address - Phone:701-526-3498
Mailing Address - Fax:701-526-3818
Practice Address - Street 1:3101 BROADWAY N
Practice Address - Street 2:SUITE C
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1485
Practice Address - Country:US
Practice Address - Phone:701-526-3498
Practice Address - Fax:701-526-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty