Provider Demographics
NPI:1396428579
Name:WILKINS, RYEZEIR
Entity type:Individual
Prefix:
First Name:RYEZEIR
Middle Name:
Last Name:WILKINS
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 1:28999 OLD TOWN FRONT ST STE 203
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5806
Mailing Address - Country:US
Mailing Address - Phone:619-721-7819
Mailing Address - Fax:
Practice Address - Street 1:28999 OLD TOWN FRONT ST STE 203
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5806
Practice Address - Country:US
Practice Address - Phone:619-721-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF4602292172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver