Healthcare Provider Details

I. General information

NPI: 1316303159
Provider Name (Legal Business Name): BRUCE WILCOX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2016
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 SPRING ST
PASO ROBLES CA
93446-1226
US

IV. Provider business mailing address

2424 SPRING ST
PASO ROBLES CA
93446-1226
US

V. Phone/Fax

Practice location:
  • Phone: 805-239-3208
  • Fax:
Mailing address:
  • Phone: 805-239-3208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: