Provider Demographics
NPI:1447820618
Name:WILEY-GUNDEN AFC
Entity type:Organization
Organization Name:WILEY-GUNDEN AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-588-6769
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-0129
Mailing Address - Country:US
Mailing Address - Phone:989-588-6769
Mailing Address - Fax:
Practice Address - Street 1:16 KAPPLINGER DR
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622-9405
Practice Address - Country:US
Practice Address - Phone:989-588-6769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities