MEDICARE: KOTEUAISA TANSWANIE WILSON CH

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	CH10077	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH10077	OTHER	FL	FL MEDICAL LICENSE

General Provider Information

NPI Number	:	1295035558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOTEUAISA TANSWANIE WILSON CH

Provider Business Mailing Address
First Line	:	202 LAKE MIRIAM DR STE W3
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2179
Country	:	US
Telephone Number	:	863-647-0808
Fax Number	:	863-250-0715

Provider Business Practice Location Address
First Line	:	202 LAKE MIRIAM DR STE W3
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2179
Country	:	US
Telephone Number	:	863-647-0808
Fax Number	:	863-250-0715

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

Provider Enumeration Date	:	11/02/2010
Last Update Date	:	10/05/2022

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Directions to “ KOTEUAISA TANSWANIE WILSON CH” Practice Location

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