Provider Demographics
NPI:1538715305
Name:WILSON, CHARLES LOUIS (LMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LOUIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 GOVERNMENT ST STE A
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5647
Mailing Address - Country:US
Mailing Address - Phone:228-861-5832
Mailing Address - Fax:
Practice Address - Street 1:2900 GOVERNMENT ST STE A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5647
Practice Address - Country:US
Practice Address - Phone:228-861-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS533225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty