Healthcare Provider Details

I. General information

NPI: 1710120563
Provider Name (Legal Business Name): WRAYCON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 MARTINWOOD DR
HAYMARKET VA
20169-2208
US

IV. Provider business mailing address

PO BOX 285
HAYMARKET VA
20168-0285
US

V. Phone/Fax

Practice location:
  • Phone: 703-470-1391
  • Fax:
Mailing address:
  • Phone: 703-470-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705117776
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number2705117776
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2705117776
License Number StateVA

VIII. Authorized Official

Name: CLYDE WILLIAM WRAY
Title or Position: PRESIDENT
Credential:
Phone: 703-470-1391