Healthcare Provider Details

I. General information

NPI: 1528344223
Provider Name (Legal Business Name): MICHAEL T WILKS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3548 IDLEWILD AVE
CINCINNATI OH
45207-1059
US

IV. Provider business mailing address

3548 IDLEWILD AVE
CINCINNATI OH
45207-1059
US

V. Phone/Fax

Practice location:
  • Phone: 734-642-5691
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number378482390999
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: