Provider Demographics
NPI:1134266125
Name:HARRIS, WILBERT
Entity type:Individual
Prefix:MR
First Name:WILBERT
Middle Name:
Last Name:HARRIS
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 1:1945 BRUSHY RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-4509
Mailing Address - Country:US
Mailing Address - Phone:931-729-2799
Mailing Address - Fax:931-729-4744
Practice Address - Street 1:1945 BRUSHY RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-4509
Practice Address - Country:US
Practice Address - Phone:931-729-2799
Practice Address - Fax:931-729-4744
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT000182Medicaid