1184794620 NPI number — DR. EARNEST JEFFERY WILES PH.D.

Table of content: DR. EARNEST JEFFERY WILES PH.D. (NPI 1184794620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184794620 NPI number — DR. EARNEST JEFFERY WILES PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILES
Provider First Name:
EARNEST
Provider Middle Name:
JEFFERY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184794620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9845 HORN ROAD
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95827-2563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-329-8555
Provider Business Mailing Address Fax Number:
916-476-4193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9845 HORN ROAD
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95827-2563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-329-8555
Provider Business Practice Location Address Fax Number:
916-476-4193
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPCC302 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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