MEDICARE: XAVIER WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	133N00000X	Nutritionist
2	133NN1002X	Nutrition Education Nutritionist
3	133V00000X	Registered Dietitian

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	814644	OTHER	NJ	ADA

General Provider Information

NPI Number	:	1982824264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XAVIER WILSON

Provider Business Mailing Address
First Line	:	832 CHANCELLOR AVE
Second Line	:
City	:	IRVINGTON
State	:	NJ
Zip	:	07111
Country	:	US
Telephone Number	:	973-399-6292
Fax Number	:	973-372-4534

Provider Business Practice Location Address
First Line	:	2003 W FULTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-2345
Country	:	US
Telephone Number	:	312-850-3438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2007
Last Update Date	:	07/26/2019

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Directions to “ XAVIER WILSON ” Practice Location

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