Provider Demographics
NPI:1093012270
Name:WILSON ELITE SERVICES, LLC
Entity Type:Organization
Organization Name:WILSON ELITE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-286-4982
Mailing Address - Street 1:1634 SW THELMA ST
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3361
Mailing Address - Country:US
Mailing Address - Phone:772-214-4559
Mailing Address - Fax:772-286-4992
Practice Address - Street 1:1634 SW THELMA ST
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3361
Practice Address - Country:US
Practice Address - Phone:772-214-4559
Practice Address - Fax:772-286-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL691506096251E00000X
FL691506098251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691506096Medicaid
FL691506098Medicaid