MEDICARE: BILLY DWAYNE 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	171WH0202X	Home Modifications Contractor

General Provider Information

NPI Number	:	1801231915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BILLY DWAYNE WILSON

Provider Business Mailing Address
First Line	:	1208 MADISON TER
Second Line	:
City	:	GLENN HEIGHTS
State	:	TX
Zip	:	75154-8833
Country	:	US
Telephone Number	:	214-557-5512
Fax Number	:	972-274-0811

Provider Business Practice Location Address
First Line	:	1208 MADISON TER
Second Line	:
City	:	GLENN HEIGHTS
State	:	TX
Zip	:	75154-8833
Country	:	US
Telephone Number	:	214-557-5512
Fax Number	:	972-274-0811

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

Provider Enumeration Date	:	05/02/2013
Last Update Date	:	05/02/2013

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Directions to “ BILLY DWAYNE WILSON ” Practice Location

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