Individual
BOBBY DEAN WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
729 W MANCHESTER AVE, LOS ANGELES, CA 90044-5720
(323) 814-9100
Mailing address
PO BOX 72001, LOS ANGELES, CA 90002-0001
(760) 558-9902
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A6251815
CA DRIVERS LICENSE
CA
Enumeration date
05/13/2021
Last updated
05/13/2021
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