Healthcare Provider Details

I. General information

NPI: 1134588379
Provider Name (Legal Business Name): MR. RON STEPHEN WHEELOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 CHISHOLM POND RD
PALERMO ME
04354-7424
US

IV. Provider business mailing address

883 CHISHOLM POND RD
PALERMO ME
04354-7424
US

V. Phone/Fax

Practice location:
  • Phone: 207-441-2673
  • Fax:
Mailing address:
  • Phone: 207-441-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberALLS-6306
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberALLS-6306
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALLS-6306
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: