Healthcare Provider Details

I. General information

NPI: 1003082603
Provider Name (Legal Business Name): MILTON JAMES WILSON L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-1648
US

IV. Provider business mailing address

4931 GUADALUPE TRL NW
ALBUQUERQUE NM
87107-3371
US

V. Phone/Fax

Practice location:
  • Phone: 505-889-3333
  • Fax:
Mailing address:
  • Phone: 505-344-5013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0434
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: