Provider Demographics
NPI:1649319948
Name:WILSON'S PROFESSIONAL CARE
Entity type:Organization
Organization Name:WILSON'S PROFESSIONAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BS, QP, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:HAMILTON
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:336-403-1414
Mailing Address - Street 1:2415 PENNY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-8121
Mailing Address - Country:US
Mailing Address - Phone:336-885-7300
Mailing Address - Fax:
Practice Address - Street 1:2415 PENNY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8121
Practice Address - Country:US
Practice Address - Phone:336-885-7300
Practice Address - Fax:336-885-7745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301548GMedicaid
NC3408378Medicaid
NC8301548BMedicaid