Provider Demographics
NPI:1306827118
Name:WILDWOOD CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:WILDWOOD CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:NAPOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-779-4263
Mailing Address - Street 1:935 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1847
Mailing Address - Country:US
Mailing Address - Phone:651-779-4263
Mailing Address - Fax:651-779-4274
Practice Address - Street 1:935 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55115-1847
Practice Address - Country:US
Practice Address - Phone:651-779-4263
Practice Address - Fax:651-779-4274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4261OtherJOHN MACK LICENSE
MN047 828 800Medicaid
MN3150OtherSCOTT DEPAULIS LICENSE
MN354 278 500Medicaid
MN367 817 200Medicaid
MN549 027 800Medicaid
MN2329OtherPATRICK G NAPOLI LICENSE
MN3051OtherDEAN JOY LICENSE
MNU38591Medicare UPIN
MN367 817 200Medicaid
MN3051OtherDEAN JOY LICENSE
MN3150OtherSCOTT DEPAULIS LICENSE
MN35000 2654Medicare ID - Type UnspecifiedJOHN MACK
MNU47692Medicare UPIN
MNU90913Medicare UPIN
MN35000 1292Medicare ID - Type UnspecifiedPATRICK G NAPOLI
MN354 278 500Medicaid