MEDICARE: WELTHY NORIVA WILSON

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	3747A0650X	Attendant Care Provider

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OTHER	OTHER	CA	COMMUNITY CARE

General Provider Information

NPI Number	:	1265082036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WELTHY NORIVA WILSON

Provider Business Mailing Address
First Line	:	311 W WOODLAND AVE
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95695-2541
Country	:	US
Telephone Number	:	707-999-8305
Fax Number	:

Provider Business Practice Location Address
First Line	:	311 W WOODLAND AVE
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95695-2541
Country	:	US
Telephone Number	:	707-999-8305
Fax Number	:

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

Provider Enumeration Date	:	09/13/2019
Last Update Date	:	09/13/2019

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