Provider Demographics
NPI:1942712625
Name:WILSON, ANTWON LOUIES
Entity Type:Individual
Prefix:
First Name:ANTWON
Middle Name:LOUIES
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 LIME AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4108
Mailing Address - Country:US
Mailing Address - Phone:562-303-2110
Mailing Address - Fax:
Practice Address - Street 1:5849 CROCKER ST UNIT L
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1311
Practice Address - Country:US
Practice Address - Phone:323-234-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator