Basic Information
| Provider Information | |||||||||
| NPI: | 1740668995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W BROADWAY | ||||||||
| Address2: | SUITE 5010 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622851330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1955 LONG BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908065501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623202426 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | Y | Agencies | Voluntary or Charitable |
No ID Information.