Provider Demographics
NPI:1114046893
Name:WIST, KIM L (DC)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:L
Last Name:WIST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:L
Other - Last Name:WIST-MANGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1331 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1354
Mailing Address - Country:US
Mailing Address - Phone:631-736-8439
Mailing Address - Fax:631-422-1076
Practice Address - Street 1:125 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-2009
Practice Address - Country:US
Practice Address - Phone:631-422-0424
Practice Address - Fax:631-422-1076
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006556111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor