1073693990 NPI number — GEORGE LARRY WHEELER SR

Table of content: (NPI 1073693990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073693990 NPI number — GEORGE LARRY WHEELER SR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE LARRY WHEELER SR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CIRCLE OF HOPE PSYCHOTHERAPY & ADDICTIONS SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073693990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 CONNECTICUT AVE NW
Provider Second Line Business Mailing Address:
SUITE 321
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20008-2509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-265-2343
Provider Business Mailing Address Fax Number:
202-248-9076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 CONNECTICUT AVE NW
Provider Second Line Business Practice Location Address:
SUITE 321
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20008-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-265-2343
Provider Business Practice Location Address Fax Number:
202-248-9076
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHEELER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
LARRY
Authorized Official Title or Position:
CEO/DIRECTOR
Authorized Official Telephone Number:
202-265-2343

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0701003368 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1073693990 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004949978 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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