Provider Demographics
NPI:1134340326
Name:WILSON, JOHN RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1455 YARMOUTH AVE.
Mailing Address - Street 2:SUITE 112
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304
Mailing Address - Country:US
Mailing Address - Phone:303-449-7414
Mailing Address - Fax:303-449-2147
Practice Address - Street 1:1455 YARMOUTH AVE.
Practice Address - Street 2:SUITE 112
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304
Practice Address - Country:US
Practice Address - Phone:303-449-7414
Practice Address - Fax:303-449-2147
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2311111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition