Provider Demographics
NPI:1508819038
Name:WILSON FAMILY CHIROPRACTIC CENTER INC.
Entity Type:Organization
Organization Name:WILSON FAMILY CHIROPRACTIC CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-232-5366
Mailing Address - Street 1:751 PROGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3108
Mailing Address - Country:US
Mailing Address - Phone:319-232-5366
Mailing Address - Fax:319-232-5370
Practice Address - Street 1:751 PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3108
Practice Address - Country:US
Practice Address - Phone:319-232-5366
Practice Address - Fax:319-232-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0485664Medicaid
IA0485672Medicaid
IAV09101Medicare UPIN
IAI17460Medicare ID - Type UnspecifiedMEDICARE GROUP
IA0485664Medicaid