Provider Demographics
NPI:1073726956
Name:CHARLES A. WICKWARE ET AL PTR
Entity Type:Organization
Organization Name:CHARLES A. WICKWARE ET AL PTR
Other - Org Name:HOME CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WICKWARE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:830-792-4663
Mailing Address - Street 1:144 FAIRWAY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6455
Mailing Address - Country:US
Mailing Address - Phone:830-792-4663
Mailing Address - Fax:
Practice Address - Street 1:144 FAIRWAY DR
Practice Address - Street 2:SUITE D
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6455
Practice Address - Country:US
Practice Address - Phone:830-792-4663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS7172OtherMEDICARE RR
CS7172OtherMEDICARE RR