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General NPI Number Information
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NPI Number | 1164693131
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Entity Type | Organization
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Legal Business Name | AARON L WILSON
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Dates
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Enumeration Date | 03/18/2008
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 913 KEITH ST NW
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City | CLEVELAND
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State | TN
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Zip | 37311-1804
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Country | US
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Telephone | 423-476-2217
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Fax | 423-476-1381
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Provider Business Mailing Address
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Address Line | 913 KEITH ST NW
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City | CLEVELAND
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State | TN
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Zip | 37311-1804
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Country | US
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Telephone | 423-476-2217
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Fax | 423-476-1381
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Authorized Official
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Title or Position | OWNER
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Name | AARON L WILSON
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Credential | A.B.O.M.
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Telephone | 423-476-2217
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | DPO0000001141
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License Number State | TN
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