Healthcare Provider Details

I. General information

NPI: 1316559743
Provider Name (Legal Business Name): JUAN WYLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12305 ARLINGTON AVE
CLEVELAND OH
44108-2359
US

IV. Provider business mailing address

2400 E 40TH ST
CLEVELAND OH
44104-1124
US

V. Phone/Fax

Practice location:
  • Phone: 216-451-5020
  • Fax:
Mailing address:
  • Phone: 216-450-7756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: