Healthcare Provider Details

I. General information

NPI: 1316489552
Provider Name (Legal Business Name): MRS. LUZVELINDA M WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-992 PAPAPUHI PL
EWA BEACH HI
96706-4722
US

IV. Provider business mailing address

91-992 PAPAPUHI PL
EWA BEACH HI
96706-4722
US

V. Phone/Fax

Practice location:
  • Phone: 808-393-9301
  • Fax: 888-958-4492
Mailing address:
  • Phone: 808-393-9301
  • Fax: 888-958-4492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number1-160072
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: