Healthcare Provider Details

I. General information

NPI: 1356366173
Provider Name (Legal Business Name): JEFF WILSON CHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 1/2 N PEARL ST
PAOLA KS
66071-1138
US

IV. Provider business mailing address

820 1/2 N PEARL ST
PAOLA KS
66071-1138
US

V. Phone/Fax

Practice location:
  • Phone: 913-294-9993
  • Fax: 913-294-9991
Mailing address:
  • Phone: 913-294-9993
  • Fax: 913-294-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberKS4077
License Number StateKS

VIII. Authorized Official

Name: DR. JEFF A WILSON
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 913-294-9993