Provider Demographics
NPI:1740493840
Name:WILSON CHIROPRACTIC
Entity type:Organization
Organization Name:WILSON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:409-866-8661
Mailing Address - Street 1:7060 PHELAN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6168
Mailing Address - Country:US
Mailing Address - Phone:409-866-8661
Mailing Address - Fax:409-866-4371
Practice Address - Street 1:7060 PHELAN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6168
Practice Address - Country:US
Practice Address - Phone:409-866-8661
Practice Address - Fax:409-866-4371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0052KVOtherBLUE CROSS GROUP ID