Healthcare Provider Details

I. General information

NPI: 1174757314
Provider Name (Legal Business Name): CASEY REED WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2009
Last Update Date: 05/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 SPRINGHILL AVE ROOM 3414
MOBILE AL
36604-3207
US

IV. Provider business mailing address

1370 PEPPERS FERRY RD NW
CHRISTIANSBURG VA
24073-5798
US

V. Phone/Fax

Practice location:
  • Phone: 251-434-3480
  • Fax:
Mailing address:
  • Phone: 540-808-8537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: