MEDICARE: DR. CHARLES R WILKERSON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	GA4956	GA

General Provider Information

NPI Number	:	1124158266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES R WILKERSON D.C.

Provider Business Mailing Address
First Line	:	4432 ALDERGATE DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-2104
Country	:	US
Telephone Number	:	770-987-4631
Fax Number	:	404-299-9991

Provider Business Practice Location Address
First Line	:	1230 S HAIRSTON RD
Second Line	:	SUITE 8
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2719
Country	:	US
Telephone Number	:	404-299-9066
Fax Number	:	404-299-9991

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	04/17/2008

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