Provider Demographics
NPI:1275646382
Name:WILDCAT CHIROPRACTIC SPORTS & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WILDCAT CHIROPRACTIC SPORTS & WELLNESS CENTER LLC
Other - Org Name:WILDCAT SPORTS & FAMILY CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC CCEP CCSP
Authorized Official - Phone:785-323-1923
Mailing Address - Street 1:404 HUMBOLDT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-5879
Mailing Address - Country:US
Mailing Address - Phone:785-323-1923
Mailing Address - Fax:785-323-1925
Practice Address - Street 1:404 HUMBOLDT ST
Practice Address - Street 2:SUITE C
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5879
Practice Address - Country:US
Practice Address - Phone:785-323-1923
Practice Address - Fax:785-323-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4457111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
660144Medicare ID - Type UnspecifiedPROVIDER NUMBER
062308Medicare PIN