Healthcare Provider Details

I. General information

NPI: 1104939156
Provider Name (Legal Business Name): LARRY WHEELER C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 SOUTHLAND DR
LEXINGTON KY
40503-1824
US

IV. Provider business mailing address

371 SOUTHLAND DR
LEXINGTON KY
40503-1824
US

V. Phone/Fax

Practice location:
  • Phone: 859-266-0420
  • Fax: 859-266-0667
Mailing address:
  • Phone: 859-266-0420
  • Fax: 859-266-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number111233
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: