Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1043464316 |
---|---|
Provider Name | Bill Wilson |
First Address | Commerce, CA 90040-2449 |
Second Address | Commerce, CA 90040-2449 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2008 |
Last Update Date | 12/11/2008 |