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General NPI Number Information
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NPI Number | 1134008568
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Entity Type | Individual
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Provider Name | TRACY BERNARD WILSON OWNER
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Gender | Male
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Dates
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Enumeration Date | 08/29/2025
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Last Update Date | 08/29/2025
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Provider Practice Location Address
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Address Line | 100 N EDWARD GARY ST STE 106
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City | SAN MARCOS
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State | TX
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Zip | 78666-5710
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Country | US
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Telephone | 608-581-5711
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Fax | 608-581-5711
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Provider Business Mailing Address
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Address Line | 1323 BUTTERFIELD RD STE 122
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-5620
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Country | US
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Telephone | 608-581-5711
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Fax | 608-581-5711
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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