MEDICARE: KEN WILSON

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1447443668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEN WILSON

Provider Business Mailing Address
First Line	:	2610 COMMONS BLVD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-2080
Country	:	US
Telephone Number	:	706-667-2353
Fax Number	:	706-667-2303

Provider Business Practice Location Address
First Line	:	2610 COMMONS BLVD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-2080
Country	:	US
Telephone Number	:	706-667-2353
Fax Number	:	706-667-2303

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. JESSICA WILSON EPPS
Credential	:	M.S.W.
Telephone Number	:	706-667-2353

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	06/23/2008

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