1205231404 NPI number — MICHELE L WILSON

Table of content: (NPI 1205231404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205231404 NPI number — MICHELE L WILSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELE L WILSON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205231404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6054 HOLLYWOOD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458-6724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-308-0814
Provider Business Mailing Address Fax Number:
561-444-4444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 VILLAGE SQUARE XING
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-3227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-308-0814
Provider Business Practice Location Address Fax Number:
561-444-4444
Provider Enumeration Date:
10/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PROVIDER & OWNER
Authorized Official Telephone Number:
561-308-0814

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH12108 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MH12108 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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