Provider Demographics
NPI:1942858162
Name:WHEATLEY, LARRY EUGENE
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:EUGENE
Last Name:WHEATLEY
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 1:8124 CHIMNEY BLUFFS ST
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89085-4402
Mailing Address - Country:US
Mailing Address - Phone:805-223-6554
Mailing Address - Fax:
Practice Address - Street 1:3435 W CRAIG RD STE C
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5116
Practice Address - Country:US
Practice Address - Phone:702-970-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant