MEDICARE: BOB WILSON MINISTRIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	2526A	TX

General Provider Information

NPI Number	:	1417174178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOB WILSON MINISTRIES

Provider Business Mailing Address
First Line	:	2114 BIRDCREEK DR
Second Line	:	SUITE 200
City	:	TEMPLE
State	:	TX
Zip	:	76502-1020
Country	:	US
Telephone Number	:	254-742-2211
Fax Number	:	254-742-2245

Provider Business Practice Location Address
First Line	:	6585 S FM 183
Second Line	:
City	:	EVANT
State	:	TX
Zip	:	76525
Country	:	US
Telephone Number	:	254-471-5709
Fax Number	:	254-471-5710

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	DR. DEWAYNE ELTON BRAWNER
Credential	:	PH. D.
Telephone Number	:	254-471-5709

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/22/2020

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