Provider Demographics
NPI:1104939156
Name:WHEELER, LARRY (CPED)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WHEELER
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1824
Mailing Address - Country:US
Mailing Address - Phone:859-266-0420
Mailing Address - Fax:859-266-0667
Practice Address - Street 1:371 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1824
Practice Address - Country:US
Practice Address - Phone:859-266-0420
Practice Address - Fax:859-266-0667
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111233224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000519294OtherANTHEM BC/BS
KY208278527OtherHUMANA
KY5574649OtherAETNA
KY7100026770Medicaid
KY5939230001OtherMEDICARE DME
KY208278527OtherTRICARE
KY000000519294OtherANTHEM BC/BS
KY5939230001Medicare NSC