Provider Demographics
NPI:1962985614
Name:MORALES, WILSON
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:MORALES
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 1:5251 FARIS ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2051 MARENGO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1352
Practice Address - Country:US
Practice Address - Phone:323-409-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379542279P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/PediatricsGroup - Single Specialty