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General NPI Number Information
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NPI Number | 1679667695
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Entity Type | Organization
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Legal Business Name | WILCO THERANET, LLC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 08/20/2012
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Provider Practice Location Address
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Address Line | 127 MEDICAL PARK LN
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City | HUNTSVILLE
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State | TX
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Zip | 77340-4972
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Country | US
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Telephone | 936-294-0283
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Fax | 936-294-9878
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Provider Business Mailing Address
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Address Line | 127 MEDICAL PARK LN
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City | HUNTSVILLE
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State | TX
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Zip | 77340-4972
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Country | US
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Telephone | 936-294-0283
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Fax | 936-294-9878
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Authorized Official
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Title or Position | PT DIRECTOR / OWNER
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Name | DALLAS C WILLIAMS
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Credential | P.T.
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Telephone | 936-294-0283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 640210000
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License Number State | TX
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