Provider Demographics
NPI:1386970168
Name:WILDER, IKE
Entity type:Individual
Prefix:MR
First Name:IKE
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 E PALMDALE BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-2034
Mailing Address - Country:US
Mailing Address - Phone:661-575-1800
Mailing Address - Fax:
Practice Address - Street 1:1529 E PALMDALE BLVD
Practice Address - Street 2:STE 150
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-2034
Practice Address - Country:US
Practice Address - Phone:661-575-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator