Healthcare Provider Details

I. General information

NPI: 1932138047
Provider Name (Legal Business Name): WILSON BRACE AND LIMB COMPANY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500J E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

IV. Provider business mailing address

500J E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-9060
  • Fax: 601-362-9911
Mailing address:
  • Phone: 601-982-9060
  • Fax: 601-362-9911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCPO02517
License Number StateDE

VIII. Authorized Official

Name: MR. JIMMY WILSON
Title or Position: PRESIDENT
Credential: CPO
Phone: 601-982-9060