Healthcare Provider Details

I. General information

NPI: 1992757637
Provider Name (Legal Business Name): WESLEY SCOTT TRUESDALE CP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MEDICAL DRIVE
ELIZ CITY NC
27909
US

IV. Provider business mailing address

PO BOX 1471 106 MEDICAL DRIVE
ELIZ CITY NC
27909
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-3002
  • Fax: 252-338-2902
Mailing address:
  • Phone: 252-338-3002
  • Fax: 252-338-2902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCP001787
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: