Provider Demographics
NPI:1215151808
Name:MBURU, WILSON N (DC)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:N
Last Name:MBURU
Suffix:
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 1:3843 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3228
Mailing Address - Country:US
Mailing Address - Phone:262-664-1241
Mailing Address - Fax:
Practice Address - Street 1:3843 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3228
Practice Address - Country:US
Practice Address - Phone:262-664-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2314-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor