Healthcare Provider Details

I. General information

NPI: 1336499771
Provider Name (Legal Business Name): WYCHOCK CONSTRUCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 UP A WAY DR
FREDERICKSBURG VA
22407-6749
US

IV. Provider business mailing address

5711 UP A WAY DR
FREDERICKSBURG VA
22407-6749
US

V. Phone/Fax

Practice location:
  • Phone: 540-604-3195
  • Fax: 540-518-9213
Mailing address:
  • Phone: 540-604-3195
  • Fax: 540-518-9213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705119134
License Number StateVA

VIII. Authorized Official

Name: ANTHONY J WYCHOCK JR.
Title or Position: OWNER
Credential:
Phone: 540-604-3195