Basic Information
| Provider Information | |||||||||
| NPI: | 1578691408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA WILSON | ||||||||
| FirstName: | MYRIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2053 N VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900271928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236615483 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 W ADAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900182039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234325185 | ||||||||
| FaxNumber: | 3234325086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.