Healthcare Provider Details

I. General information

NPI: 1548366388
Provider Name (Legal Business Name): GEORGE CARL WILSON JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 DEWEY AVE #974
FERNDALE CA
95536-0974
US

IV. Provider business mailing address

1025 DEWEY AVE #974
FERNDALE CA
95536-0974
US

V. Phone/Fax

Practice location:
  • Phone: 707-298-4131
  • Fax: 559-224-8502
Mailing address:
  • Phone: 707-298-4131
  • Fax: 559-224-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number17524
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: