Provider Demographics
NPI:1740668995
Name:WILSON, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
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 1:100 W BROADWAY
Mailing Address - Street 2:SUITE 5010
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4431
Mailing Address - Country:US
Mailing Address - Phone:562-285-1330
Mailing Address - Fax:
Practice Address - Street 1:1955 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5501
Practice Address - Country:US
Practice Address - Phone:562-320-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable