Provider Demographics
NPI:1508393398
Name:WYATT CHIROPRACTIC
Entity Type:Organization
Organization Name:WYATT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-802-6711
Mailing Address - Street 1:170 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5023
Mailing Address - Country:US
Mailing Address - Phone:931-802-6711
Mailing Address - Fax:931-802-6712
Practice Address - Street 1:170 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5023
Practice Address - Country:US
Practice Address - Phone:931-802-6711
Practice Address - Fax:931-802-6712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2098111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000000630607OtherANTHEM PIN