Healthcare Provider Details

I. General information

NPI: 1285549113
Provider Name (Legal Business Name): VICTOR J WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10364 SWEET BAY DR
GULFPORT MS
39503-7520
US

IV. Provider business mailing address

10364 SWEET BAY DR
GULFPORT MS
39503-7520
US

V. Phone/Fax

Practice location:
  • Phone: 228-313-8678
  • Fax:
Mailing address:
  • Phone:
  • Fax: 228-313-8678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: