Basic Information
| Provider Information | |||||||||
| NPI: | 1659445302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENCK | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 E SUNSET RD | ||||||||
| Address2: | UNIT 5-260 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891203511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027980113 | ||||||||
| FaxNumber: | 8662915242 | ||||||||
| Practice Location | |||||||||
| Address1: | 2866 TAMIAMI TRL | ||||||||
| Address2: | SUITE D | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339525126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412550038 | ||||||||
| FaxNumber: | 9412550728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 12/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | AS2799 | FL | Y | Other Service Providers | Specialist |
No ID Information.