Healthcare Provider Details

I. General information

NPI: 1710273503
Provider Name (Legal Business Name): WILSON PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MAPLE AVE SUITE 7A
RED BANK NJ
07701-1734
US

IV. Provider business mailing address

130 MAPLE AVE SUITE 7A
RED BANK NJ
07701-1734
US

V. Phone/Fax

Practice location:
  • Phone: 732-842-7004
  • Fax:
Mailing address:
  • Phone: 732-842-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number38MC00385100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number40QA01025400
License Number StateNJ

VIII. Authorized Official

Name: DR. PAMELA EILEEN WILSON
Title or Position: OWNER
Credential: DC
Phone: 732-842-7004