Provider Demographics
NPI:1588748313
Name:WILSON, CRAIG LOUIS (DC)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:LOUIS
Last Name:WILSON
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 1:1272 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345
Mailing Address - Country:US
Mailing Address - Phone:616-887-8967
Mailing Address - Fax:616-696-2650
Practice Address - Street 1:26 S MAIN
Practice Address - Street 2:BOX 279
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319
Practice Address - Country:US
Practice Address - Phone:616-696-2650
Practice Address - Fax:616-696-2650
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004937111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CW004937OtherBCBS LICENSE #
350045875OtherRAILROAD MEDICARE #
950D150030OtherBCBS PIN#
950D150030OtherBCBS PIN#
350045875OtherRAILROAD MEDICARE #