Provider Demographics
NPI:1760855688
Name:WHEELER, JUSTIN (MS, ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WHEELER
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 W ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71272-2711
Mailing Address - Country:US
Mailing Address - Phone:318-257-4789
Mailing Address - Fax:
Practice Address - Street 1:1450 W ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71272-2711
Practice Address - Country:US
Practice Address - Phone:318-257-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000110732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer