MEDICARE: CHARLES LOUIS WILSON LMT

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	225700000X	Massage Therapist	533	MS

General Provider Information

NPI Number	:	1538715305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES LOUIS WILSON LMT

Provider Business Mailing Address
First Line	:	2900 GOVERNMENT ST STE A
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-5647
Country	:	US
Telephone Number	:	228-861-5832
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 GOVERNMENT ST STE A
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-5647
Country	:	US
Telephone Number	:	228-861-5832
Fax Number	:

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

Provider Enumeration Date	:	08/16/2019
Last Update Date	:	08/16/2019

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Directions to “ CHARLES LOUIS WILSON LMT” Practice Location

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