Healthcare Provider Details

I. General information

NPI: 1245166172
Provider Name (Legal Business Name): EDLA KALU WILSON III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDDIE KALU WILSON III

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12760 S PARK AVE UNIT 520
RIVERTON UT
84065-3422
US

IV. Provider business mailing address

2264 N CHURCH ST
LAYTON UT
84040-7019
US

V. Phone/Fax

Practice location:
  • Phone: 801-382-8016
  • Fax:
Mailing address:
  • Phone: 808-854-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: