Healthcare Provider Details

I. General information

NPI: 1912141516
Provider Name (Legal Business Name): NELSON WILSON, IV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E NORTHSIDE DR SUITE D
CLINTON MS
39056-3663
US

IV. Provider business mailing address

801 E NORTHSIDE DR SUITE D
CLINTON MS
39056-3663
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-2888
  • Fax: 601-924-2885
Mailing address:
  • Phone: 601-924-2888
  • Fax: 601-924-2885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberC36423
License Number StateMS

VIII. Authorized Official

Name: MR. NELSON WILSON IV
Title or Position: OWNER
Credential: C.P.
Phone: 601-951-7012