MEDICARE: WILSON RESIDENTIAL SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	7600804	OH

General Provider Information

NPI Number	:	1073632998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON RESIDENTIAL SERVICES INC

Provider Business Mailing Address
First Line	:	6815 WILLIAM TELL AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-6547
Country	:	US
Telephone Number	:	330-224-1041
Fax Number	:

Provider Business Practice Location Address
First Line	:	6815 WILLIAM TELL AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-6547
Country	:	US
Telephone Number	:	330-224-1041
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. LARRY MICHAEL WILSON
Credential	:
Telephone Number	:	330-224-1041

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	08/22/2020

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