Provider Demographics
NPI:1346456498
Name:WICKISER CLINIC OF CHIROPRACTIC
Entity Type:Organization
Organization Name:WICKISER CLINIC OF CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WICKISER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-224-0246
Mailing Address - Street 1:3618 E RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-7334
Mailing Address - Country:US
Mailing Address - Phone:864-224-0246
Mailing Address - Fax:864-224-2524
Practice Address - Street 1:3618 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7334
Practice Address - Country:US
Practice Address - Phone:864-224-0246
Practice Address - Fax:864-224-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2599Medicaid
SCGCH104Medicaid
SCT25040Medicare UPIN
SCGCH104Medicaid