Provider Demographics
NPI:1922138239
Name:WILSON, THOMAS L (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
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:PO BOX 992378
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-2378
Mailing Address - Country:US
Mailing Address - Phone:530-223-2021
Mailing Address - Fax:530-223-3992
Practice Address - Street 1:2185 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0747
Practice Address - Country:US
Practice Address - Phone:530-221-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11536111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0115360Medicare ID - Type Unspecified
CAT04384Medicare UPIN