Healthcare Provider Details

I. General information

NPI: 1326178294
Provider Name (Legal Business Name): PETER J WILSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BARCLAY CIR SE
MARIETTA GA
30060-2943
US

IV. Provider business mailing address

509 LOVINGGOOD CT
WOODSTOCK GA
30189-7410
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-2786
  • Fax: 770-792-6113
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR0002120
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number2120
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: