Provider Demographics
NPI:1356454516
Name:WILDE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:WILDE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-756-8833
Mailing Address - Street 1:246 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2829
Mailing Address - Country:US
Mailing Address - Phone:801-756-8833
Mailing Address - Fax:801-756-9014
Practice Address - Street 1:246 S 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2829
Practice Address - Country:US
Practice Address - Phone:801-756-8833
Practice Address - Fax:801-756-9014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT290149-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty