Individual
JACK LARRY WISDOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CSA
Contact information
Practice address
5974 PENTZ RD, PARADISE, CA 95969-5509
(530) 876-7903
Mailing address
261 TRANQUIL DR, PARADISE, CA 95969-3707
(530) 876-8533
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
718316
CA
163W00000X
Registered Nurse
96534
TN
Other
Enumeration date
02/21/2014
Last updated
02/21/2014
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