Provider Demographics
NPI:1861761066
Name:WILSON, ZACH (DC)
Entity type:Individual
Prefix:DR
First Name:ZACH
Middle Name:
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 1:605 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1600
Mailing Address - Country:US
Mailing Address - Phone:309-678-8605
Mailing Address - Fax:
Practice Address - Street 1:700 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-2749
Practice Address - Country:US
Practice Address - Phone:920-542-1028
Practice Address - Fax:920-542-1027
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012081111NS0005X
WI4867-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor