MEDICARE: MR. RONNELL M 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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1821431552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONNELL M WILSON

Provider Business Mailing Address
First Line	:	5400 W CHEYENNE AVE
Second Line	:	APT 1106
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-4724
Country	:	US
Telephone Number	:	951-250-1868
Fax Number	:

Provider Business Practice Location Address
First Line	:	5175 CAMINO AL NORTE
Second Line	:	SUIT 100
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2407
Country	:	US
Telephone Number	:	702-648-3913
Fax Number	:

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

Provider Enumeration Date	:	04/11/2013
Last Update Date	:	04/11/2013

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