Provider Demographics
NPI:1699401018
Name:B. GALE WILSON MTU
Entity Type:Organization
Organization Name:B. GALE WILSON MTU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHN MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES-ESPY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-784-8653
Mailing Address - Street 1:275 BECK AVE # MS 5-175
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3305 CHERRY HILLS CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7870
Practice Address - Country:US
Practice Address - Phone:707-784-8650
Practice Address - Fax:707-421-7484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation