MEDICARE: DR. MICHAEL COLE WILSON 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	31747	CA

General Provider Information

NPI Number	:	1487968111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL COLE WILSON D.C.

Provider Business Mailing Address
First Line	:	4432 INGRAHAM ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4404
Country	:	US
Telephone Number	:	858-270-2225
Fax Number	:	858-270-6898

Provider Business Practice Location Address
First Line	:	4432 INGRAHAM ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4404
Country	:	US
Telephone Number	:	858-270-2225
Fax Number	:	858-270-6898

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

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	08/05/2010

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