Healthcare Provider Details

I. General information

NPI: 1588845762
Provider Name (Legal Business Name): JAMES REGINALD WYCHE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 RADFORD BLVD SUITE 20328
ALBANY GA
31704-1130
US

IV. Provider business mailing address

814 RADFORD BLVD PSC 20012
ALBANY GA
31704-1130
US

V. Phone/Fax

Practice location:
  • Phone: 229-639-7764
  • Fax:
Mailing address:
  • Phone: 229-369-7764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: