MEDICARE: WILSON DURABLE MEDICAL EQUIPMENT

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	332B00000X	Durable Medical Equipment & Medical Supplies		TX

General Provider Information

NPI Number	:	1417221102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON DURABLE MEDICAL EQUIPMENT

Provider Business Mailing Address
First Line	:	2806 JESSICA LN
Second Line	:
City	:	LUCAS
State	:	TX
Zip	:	75002-3703
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2806 JESSICA LANE
Second Line	:
City	:	LUCAS
State	:	TX
Zip	:	75002
Country	:	US
Telephone Number	:	469-323-5474
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHELLE ELLEN WILSON
Credential	:
Telephone Number	:	469-323-5474

Provider Enumeration Date	:	02/28/2012
Last Update Date	:	02/28/2012

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