Provider Demographics
NPI:1437371234
Name:WILDWOOD CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:WILDWOOD CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EDELMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-458-9334
Mailing Address - Street 1:16841 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:GROVER
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1207
Mailing Address - Country:US
Mailing Address - Phone:636-458-9334
Mailing Address - Fax:
Practice Address - Street 1:16841 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:GROVER
Practice Address - State:MO
Practice Address - Zip Code:63040-1207
Practice Address - Country:US
Practice Address - Phone:636-458-9334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE006482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU62414Medicare UPIN