Provider Demographics
NPI:1184979189
Name:KENNETH L. WILEY, LLC
Entity type:Organization
Organization Name:KENNETH L. WILEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-309-9140
Mailing Address - Street 1:3308 TULANE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7100
Mailing Address - Country:US
Mailing Address - Phone:504-309-9140
Mailing Address - Fax:504-309-9317
Practice Address - Street 1:3308 TULANE AVE STE 200
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7100
Practice Address - Country:US
Practice Address - Phone:504-309-9140
Practice Address - Fax:504-309-9317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09539R173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1965669Medicaid
LAB04156Medicare UPIN