Provider Demographics
NPI:1356701601
Name:VAN WINKLE, WILBUR III (LMT)
Entity type:Individual
Prefix:MR
First Name:WILBUR
Middle Name:
Last Name:VAN WINKLE
Suffix:III
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 SUMMERFIELD DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-4811
Mailing Address - Country:US
Mailing Address - Phone:615-423-1442
Mailing Address - Fax:
Practice Address - Street 1:1704 SUMMERFIELD DR APT 1
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-4811
Practice Address - Country:US
Practice Address - Phone:615-423-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10962225700000X
TX113838225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist