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General NPI Number Information
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NPI Number | 1528699352
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Entity Type | Organization
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Legal Business Name | OUTREACH HEALTH INCORPORATED
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Dates
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Enumeration Date | 01/30/2020
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Last Update Date | 01/30/2020
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Provider Practice Location Address
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Address Line | 240 N FREDERICK AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-3400
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Country | US
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Telephone | 386-255-5569
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Fax | 386-257-1245
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Provider Business Mailing Address
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Address Line | 240 N FREDERICK AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-3400
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Country | US
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Telephone | 386-255-5569
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Fax | 386-257-1245
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | DR. CHESTER LEE WILSON JR.
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Credential | ED.D.
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Telephone | 386-675-0098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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