Provider Demographics
NPI:1700320629
Name:WHEELER CLINIC
Entity Type:Organization
Organization Name:WHEELER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER IV
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:IVETTE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-793-7241
Mailing Address - Street 1:115 WOOD AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1046
Mailing Address - Country:US
Mailing Address - Phone:203-584-5717
Mailing Address - Fax:
Practice Address - Street 1:458 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3856
Practice Address - Country:US
Practice Address - Phone:203-752-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management