Provider Demographics
NPI:1366560518
Name:WILSON, LAWRENCE JOE (DC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JOE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:LAWRENCE
Other - Middle Name:J
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:10769 WOODSIDE AVE
Mailing Address - Street 2:109
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3174
Mailing Address - Country:US
Mailing Address - Phone:619-449-7474
Mailing Address - Fax:619-449-7472
Practice Address - Street 1:10769 WOODSIDE AVE
Practice Address - Street 2:109
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3174
Practice Address - Country:US
Practice Address - Phone:619-449-7474
Practice Address - Fax:619-449-7472
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2186259-4111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10697Medicare ID - Type Unspecified