Provider Demographics
NPI:1659445302
Name:WENCK, RAYMOND F (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:F
Last Name:WENCK
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E SUNSET RD
Mailing Address - Street 2:UNIT 5-260
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3511
Mailing Address - Country:US
Mailing Address - Phone:702-798-0113
Mailing Address - Fax:866-291-5242
Practice Address - Street 1:2866 TAMIAMI TRL
Practice Address - Street 2:SUITE D
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5126
Practice Address - Country:US
Practice Address - Phone:941-255-0038
Practice Address - Fax:941-255-0728
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2799174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ8017OtherBLUE CROSS PROVIDER NUMBE