Healthcare Provider Details

I. General information

NPI: 1588910509
Provider Name (Legal Business Name): HUDSON ALEXANDER WILVERS P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6930 WARNER AVE
HUNTINGTON BEACH CA
92647-5316
US

IV. Provider business mailing address

200 NEWPORT CENTER DR #213
NEWPORT BEACH CA
92660-7501
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-3800
  • Fax: 714-847-1413
Mailing address:
  • Phone: 714-847-3800
  • Fax: 714-847-1413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 39186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: