Provider Demographics
NPI:1396890547
Name:WILSON, THOMAS EDWARD (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
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 1:777 E. WATER ST.
Mailing Address - Street 2:1 PLAZA DR. SUITE 6
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064
Mailing Address - Country:US
Mailing Address - Phone:765-778-5251
Mailing Address - Fax:
Practice Address - Street 1:777 E WATER ST
Practice Address - Street 2:1 PLAZA DR. SUITE 6
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9317
Practice Address - Country:US
Practice Address - Phone:765-778-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001732A111N00000X
MI2301002395111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000496434Medicare UPIN
MIT32620Medicare UPIN
MIN87600006Medicare PIN