Healthcare Provider Details

I. General information

NPI: 1427220508
Provider Name (Legal Business Name): MICHAEL LYLE WILSON PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WALNUT ST
MANISTIQUE MI
49854-1435
US

IV. Provider business mailing address

101 WALNUT ST
MANISTIQUE MI
49854-1435
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-5689
  • Fax: 906-341-5723
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02482
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number02482
License Number StateMI

VIII. Authorized Official

Name: MARIE BELLVILLE
Title or Position: ASSISTANT
Credential:
Phone: 906-341-5689