Basic Information
| Provider Information | |||||||||
| NPI: | 1164553236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 93156 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911093156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068261367 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14550 SHERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914052210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189084990 | ||||||||
| FaxNumber: | 8189973138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 06/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.