Provider Demographics
NPI:1366957656
Name:ROBERT WILSON, DC, PLLC
Entity type:Organization
Organization Name:ROBERT WILSON, DC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-729-4001
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-0099
Mailing Address - Country:US
Mailing Address - Phone:931-729-4001
Mailing Address - Fax:931-729-4081
Practice Address - Street 1:132A N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033
Practice Address - Country:US
Practice Address - Phone:931-729-4001
Practice Address - Fax:931-729-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
6128617OtherBLUE CROSS BLUE SHIED OF TENNESSEE
1144589458OtherNPPES - INDIVIDUAL NPI