Healthcare Provider Details

I. General information

NPI: 1245856418
Provider Name (Legal Business Name): DAVID DEMETRIUS WILSON DC, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 SW MAIN ST
LEES SUMMIT MO
64063-2340
US

IV. Provider business mailing address

1627 SW MANOR LAKE DR
LEES SUMMIT MO
64082-4183
US

V. Phone/Fax

Practice location:
  • Phone: 816-600-5483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2019040226
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: