1366957656 NPI number — ROBERT WILSON, DC, PLLC

Table of content: (NPI 1366957656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366957656 NPI number — ROBERT WILSON, DC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT WILSON, DC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366957656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37033-0099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-729-4001
Provider Business Mailing Address Fax Number:
931-729-4081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132A N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-729-4001
Provider Business Practice Location Address Fax Number:
931-729-4081
Provider Enumeration Date:
12/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
931-729-4001

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6128617 . This is a "BLUE CROSS BLUE SHIED OF TENNESSEE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1144589458 . This is a "NPPES - INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".




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