Healthcare Provider Details

I. General information

NPI: 1164573085
Provider Name (Legal Business Name): JOSEPH WILSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S TELSHOR BLVD STE 102
LAS CRUCES NM
88011-4688
US

IV. Provider business mailing address

880 S TELSHOR BLVD STE 220
LAS CRUCES NM
88011-8682
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-1116
  • Fax: 575-532-7050
Mailing address:
  • Phone: 575-649-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4937
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number853
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: