MEDICARE: MR. RONALD ROLAND WILSON JR. LPN

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	164W00000X	Licensed Practical Nurse	104511	OH

General Provider Information

NPI Number	:	1669750287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONALD ROLAND WILSON JR. LPN

Provider Business Mailing Address
First Line	:	6735 DEER CT
Second Line	:
City	:	BEDFORD HEIGHTS
State	:	OH
Zip	:	44146-4868
Country	:	US
Telephone Number	:	216-218-1303
Fax Number	:

Provider Business Practice Location Address
First Line	:	6735 DEER CT
Second Line	:
City	:	BEDFORD HEIGHTS
State	:	OH
Zip	:	44146-4868
Country	:	US
Telephone Number	:	216-218-1303
Fax Number	:

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

Provider Enumeration Date	:	07/31/2011
Last Update Date	:	07/31/2011

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