Provider Demographics
NPI:1396793147
Name:GREENE, WILEY A (DC)
Entity type:Individual
Prefix:
First Name:WILEY
Middle Name:A
Last Name:GREENE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-3608
Mailing Address - Country:US
Mailing Address - Phone:276-642-0107
Mailing Address - Fax:276-642-0347
Practice Address - Street 1:1914 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3608
Practice Address - Country:US
Practice Address - Phone:276-642-0107
Practice Address - Fax:276-642-0347
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6708935Medicaid
VA350000892Medicare ID - Type Unspecified
VAU10079Medicare UPIN