Healthcare Provider Details

I. General information

NPI: 1134510761
Provider Name (Legal Business Name): SEITHEACH WILSON N.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9620 S LAS VEGAS BLVD SUITE E4 #1017
LAS VEGAS NV
89123-6508
US

IV. Provider business mailing address

ONE BONIFACIO HIGH STREET
TAGUIG METRO MANILA
01630
PH

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number22131202003186
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: