Healthcare Provider Details

I. General information

NPI: 1487386652
Provider Name (Legal Business Name): WILSON TJHIA RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD
MARTINEZ CA
94553-4668
US

IV. Provider business mailing address

150 MUIR RD
MARTINEZ CA
94553-4668
US

V. Phone/Fax

Practice location:
  • Phone: 925-372-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86070012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: