Provider Demographics
NPI:1083201347
Name:WILSON & ALLEN CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:WILSON & ALLEN CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:SHERRI
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:209-334-6947
Mailing Address - Street 1:2000 W KETTLEMAN LN STE 104
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4334
Mailing Address - Country:US
Mailing Address - Phone:209-334-6947
Mailing Address - Fax:209-334-6969
Practice Address - Street 1:2000 W KETTLEMAN LN STE 104
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4334
Practice Address - Country:US
Practice Address - Phone:209-334-6947
Practice Address - Fax:209-334-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4379OtherCORPORATE CERTIFICATE