Provider Demographics
NPI:1902881865
Name:WILSON, KEN II (DC)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:WILSON
Suffix:II
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S JUPITER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-3052
Mailing Address - Country:US
Mailing Address - Phone:214-547-7234
Mailing Address - Fax:214-547-7236
Practice Address - Street 1:309 S JUPITER RD
Practice Address - Street 2:STE 100
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-3052
Practice Address - Country:US
Practice Address - Phone:214-547-7234
Practice Address - Fax:214-547-7236
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611952Medicare PIN