MEDICARE: MR. CLARENCE EDWARD WESLEY PERSONAL PROVIDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320700000X	Physical Disabilities Residential Treatment Facility		VA

General Provider Information

NPI Number	:	1184994675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLARENCE EDWARD WESLEY PERSONAL PROVIDER

Provider Business Mailing Address
First Line	:	2539 GALTS MILL RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	VA
Zip	:	24572-5808
Country	:	US
Telephone Number	:	434-316-4778
Fax Number	:	434-845-0856

Provider Business Practice Location Address
First Line	:	2539 GALTS MILL RD
Second Line	:	2539 GALTS MILL RD
City	:	MADISON HEIGHTS
State	:	VA
Zip	:	24572-5808
Country	:	US
Telephone Number	:	434-316-4778
Fax Number	:	434-845-0856

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2011
Last Update Date	:	12/30/2011

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