Healthcare Provider Details

I. General information

NPI: 1952834764
Provider Name (Legal Business Name): RENALDO WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105 W GOLDLEAF CIR
LOS ANGELES CA
90056-1269
US

IV. Provider business mailing address

5105 W GOLDLEAF CIR
LOS ANGELES CA
90056-1269
US

V. Phone/Fax

Practice location:
  • Phone: 323-298-3328
  • Fax:
Mailing address:
  • Phone: 323-298-3328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: