Basic Information
| Provider Information | |||||||||
| NPI: | 1265991988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDI | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236828840 | ||||||||
| FaxNumber: | 4236022028 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 SE 96TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972161150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035467640 | ||||||||
| FaxNumber: | 5035467641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2019 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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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 | 225100000X | 63117 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.