Provider Demographics
NPI:1205933801
Name:ROBERT J. WHEELER
Entity type:Organization
Organization Name:ROBERT J. WHEELER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:865-429-0064
Mailing Address - Street 1:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:KODAK
Mailing Address - State:TN
Mailing Address - Zip Code:37764-0513
Mailing Address - Country:US
Mailing Address - Phone:865-429-0064
Mailing Address - Fax:865-429-8543
Practice Address - Street 1:129 BRUCE ST
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3501
Practice Address - Country:US
Practice Address - Phone:865-429-0064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000609332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3560590Medicaid
0327150001Medicare NSC