MEDICARE: QUINTON 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	251C00000X	Developmentally Disabled Services Day Training Agency	129611400	FL

General Provider Information

NPI Number	:	1932057551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUINTON WILSON

Provider Business Mailing Address
First Line	:	5519 MYRTICE LN
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-3200
Country	:	US
Telephone Number	:	863-409-1135
Fax Number	:

Provider Business Practice Location Address
First Line	:	5519 MYRTICE LN
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-3200
Country	:	US
Telephone Number	:	863-409-1135
Fax Number	:

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

Provider Enumeration Date	:	03/19/2026
Last Update Date	:	03/19/2026

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Directions to “ QUINTON WILSON ” Practice Location

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