Provider Demographics
NPI:1104326438
Name:WHEATLEY DE FORGE LLC
Entity type:Organization
Organization Name:WHEATLEY DE FORGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DEFORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:027-778-9875
Mailing Address - Street 1:6900 WESTCLIFF DR STE 504
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0198
Mailing Address - Country:US
Mailing Address - Phone:702-787-7059
Mailing Address - Fax:702-778-9863
Practice Address - Street 1:6900 WESTCLIFF DR STE 504
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0198
Practice Address - Country:US
Practice Address - Phone:702-778-9875
Practice Address - Fax:702-778-9863
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NV20161161415
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-13
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NV1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100532491Medicaid
NV100532491Medicaid