Healthcare Provider Details

I. General information

NPI: 1083569149
Provider Name (Legal Business Name): WILSON PROFESSIONAL SERVICES TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 N QUEEN ST
KINSTON NC
28501-1632
US

IV. Provider business mailing address

5001 SPRING VALLEY ROAD SUITE 600 EAST
DALLAS TX
75244
US

V. Phone/Fax

Practice location:
  • Phone: 208-283-7792
  • Fax:
Mailing address:
  • Phone: 208-283-7792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY KILGORE
Title or Position: CEO
Credential:
Phone: 208-283-7792