Provider Demographics
NPI:1720293699
Name:WILSON CHIROPRACTIC AND ACUPUNCTURE PLLC
Entity Type:Organization
Organization Name:WILSON CHIROPRACTIC AND ACUPUNCTURE PLLC
Other - Org Name:EAST TEXAS FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-535-9355
Mailing Address - Street 1:1040 S FLEISHEL AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2044
Mailing Address - Country:US
Mailing Address - Phone:903-535-9355
Mailing Address - Fax:903-535-5053
Practice Address - Street 1:1040 S FLEISHEL AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2044
Practice Address - Country:US
Practice Address - Phone:903-535-9355
Practice Address - Fax:903-535-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty