Provider Demographics
NPI:1558844472
Name:WILEY, JUSTIN BENNETT
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BENNETT
Last Name:WILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 TELLER ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-8057
Mailing Address - Country:US
Mailing Address - Phone:303-233-2808
Mailing Address - Fax:
Practice Address - Street 1:3113 TELLER ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-8057
Practice Address - Country:US
Practice Address - Phone:303-233-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO230414310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO230414Medicaid