MEDICARE: MR. WILSON G BRYANT III

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1225718877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILSON G BRYANT III

Provider Business Mailing Address
First Line	:	19196 PINE WAY
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-4914
Country	:	US
Telephone Number	:	760-490-7367
Fax Number	:

Provider Business Practice Location Address
First Line	:	19196 PINE WAY
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-4914
Country	:	US
Telephone Number	:	760-490-7367
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2023
Last Update Date	:	07/19/2023

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