MEDICARE: WILSON FAMILY CHIROPRACTIC P.A.

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	111N00000X	Chiropractor	5991	MN

General Provider Information

NPI Number	:	1629469978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON FAMILY CHIROPRACTIC P.A.

Provider Business Mailing Address
First Line	:	943 WILDWOOD RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55115-1847
Country	:	US
Telephone Number	:	651-797-4238
Fax Number	:	651-888-2242

Provider Business Practice Location Address
First Line	:	6466 KINGS DR
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-2523
Country	:	US
Telephone Number	:	651-249-4181
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CLIFFORD JAMES WILSON
Credential	:	D.C.
Telephone Number	:	651-249-4181

Provider Enumeration Date	:	02/09/2015
Last Update Date	:	08/26/2015

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