Provider Demographics
NPI:1780785691
Name:WILSON, HOLLIS LEROY III (DC)
Entity type:Individual
Prefix:
First Name:HOLLIS
Middle Name:LEROY
Last Name:WILSON
Suffix:III
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 1:15300 B FM 1825
Mailing Address - Street 2:SUITE 114
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660
Mailing Address - Country:US
Mailing Address - Phone:512-989-7477
Mailing Address - Fax:512-989-7478
Practice Address - Street 1:15300 B FM 1825
Practice Address - Street 2:SUITE 114
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660
Practice Address - Country:US
Practice Address - Phone:512-989-7477
Practice Address - Fax:512-989-7478
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U6820OtherBCBS
TX6950152OtherCIGNA
TX8D1476Medicare PIN
TX6950152OtherCIGNA