Provider Demographics
NPI:1275867004
Name:WILDER AND WILDER, LLC
Entity Type:Organization
Organization Name:WILDER AND WILDER, LLC
Other - Org Name:BODY ENERGETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-695-1177
Mailing Address - Street 1:175 W NEW HAMPSHIRE AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-4826
Mailing Address - Country:US
Mailing Address - Phone:910-695-1177
Mailing Address - Fax:
Practice Address - Street 1:175 W NEW HAMPSHIRE AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4826
Practice Address - Country:US
Practice Address - Phone:910-695-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-27
Last Update Date:2009-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC893225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC671190671190OtherBLUE CROSS BLUE SHIELD