Healthcare Provider Details

I. General information

NPI: 1922995596
Provider Name (Legal Business Name): CECIL CLINTON WILHELM III MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 1675 RD
DELTA CO
81416-3462
US

IV. Provider business mailing address

734 ANTELOPE ST
DELTA CO
81416-3345
US

V. Phone/Fax

Practice location:
  • Phone: 970-985-1491
  • Fax:
Mailing address:
  • Phone: 970-975-0163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0027576
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: