Provider Demographics
NPI:1043221203
Name:WHEELOCK, GARY DEAN (DC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DEAN
Last Name:WHEELOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2301
Mailing Address - Country:US
Mailing Address - Phone:218-326-2714
Mailing Address - Fax:218-326-2219
Practice Address - Street 1:605 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2301
Practice Address - Country:US
Practice Address - Phone:218-326-2714
Practice Address - Fax:218-326-2219
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN73550WHOtherBCBS
MN767325600Medicaid
T66287Medicare UPIN
MN350001354Medicare ID - Type Unspecified