MEDICARE: CHANDRA C WILSON PT

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	225100000X	Physical Therapist	PTH3513	AL

General Provider Information

NPI Number	:	1629134671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDRA C WILSON PT

Provider Business Mailing Address
First Line	:	1013 BARON LN
Second Line	:
City	:	CHELSEA
State	:	AL
Zip	:	35043-6628
Country	:	US
Telephone Number	:	205-678-4849
Fax Number	:

Provider Business Practice Location Address
First Line	:	3319 DR JOHN HAYNES DR STE 4
Second Line	:
City	:	PELL CITY
State	:	AL
Zip	:	35125-1583
Country	:	US
Telephone Number	:	205-338-8440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/08/2007

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