Provider Demographics
NPI:1700950771
Name:WILSON, MARK (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WILSON
Suffix:
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 1:2801 GREAT NORTHERN LOOP
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1745
Mailing Address - Country:US
Mailing Address - Phone:406-549-9100
Mailing Address - Fax:406-549-9151
Practice Address - Street 1:2300 GREAT NORTHERN AVE STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1726
Practice Address - Country:US
Practice Address - Phone:406-549-9100
Practice Address - Fax:406-549-9151
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT826111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000004516Medicare ID - Type Unspecified