Provider Demographics
NPI:1134719800
Name:WILSON, SEYMOURA RAYCHANEL (CRT HAIR LOSS SPT)
Entity type:Individual
Prefix:
First Name:SEYMOURA
Middle Name:RAYCHANEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRT HAIR LOSS SPT
Other - Prefix:
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Mailing Address - Street 1:1915 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1316
Mailing Address - Country:US
Mailing Address - Phone:323-614-1465
Mailing Address - Fax:
Practice Address - Street 1:3411 CRENSHAW BLVD APT 511
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4879
Practice Address - Country:US
Practice Address - Phone:323-614-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier