Healthcare Provider Details

I. General information

NPI: 1649116963
Provider Name (Legal Business Name): JUSTIN BENJAMIN WHEELER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 W 19TH ST
ASHTABULA OH
44004-9722
US

IV. Provider business mailing address

2633 W 19TH ST
ASHTABULA OH
44004-9721
US

V. Phone/Fax

Practice location:
  • Phone: 440-813-0674
  • Fax:
Mailing address:
  • Phone: 440-813-0674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberUC956046
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: