Provider Demographics
NPI:1851732697
Name:WILSON, KEITH (CPO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 HIGHPOINT TER
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8841
Mailing Address - Country:US
Mailing Address - Phone:615-500-4639
Mailing Address - Fax:
Practice Address - Street 1:1823 CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2104
Practice Address - Country:US
Practice Address - Phone:615-340-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier