Provider Demographics
NPI:1134008568
Name:WILSON, TRACY BERNARD (OWNER)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:BERNARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1323 BUTTERFIELD RD STE 122
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5620
Mailing Address - Country:US
Mailing Address - Phone:608-581-5711
Mailing Address - Fax:608-581-5711
Practice Address - Street 1:100 N EDWARD GARY ST STE 106
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5710
Practice Address - Country:US
Practice Address - Phone:608-581-5711
Practice Address - Fax:608-581-5711
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies