Basic Information
| Provider Information | |||||||||
| NPI: | 1649922097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILDER WELLNESS & PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 ROSEBUD CT | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371290228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658508050 | ||||||||
| FaxNumber: | 6157472114 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 ROSEBUD CT | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371290228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658508050 | ||||||||
| FaxNumber: | 6157472114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2022 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILDER | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8658508050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT, ATC | ||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.