Healthcare Provider Details

I. General information

NPI: 1578088993
Provider Name (Legal Business Name): JIMMY L. WILSON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 OLD GROVE LN
ALTAMONTE SPRINGS FL
32701-7947
US

IV. Provider business mailing address

1096 HOWELL HARBOR DR
CASSELBERRY FL
32707-5811
US

V. Phone/Fax

Practice location:
  • Phone: 407-497-8446
  • Fax:
Mailing address:
  • Phone: 407-497-8446
  • Fax: 407-951-5634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: HIROKO SHIMODA
Title or Position: CEO
Credential:
Phone: 407-497-8446