Provider Demographics
NPI:1508941071
Name:WILD, ALAN DUNBAR (DC)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DUNBAR
Last Name:WILD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2953
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25728-2953
Mailing Address - Country:US
Mailing Address - Phone:304-697-7080
Mailing Address - Fax:304-697-0669
Practice Address - Street 1:1423 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-697-7080
Practice Address - Fax:304-697-0669
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV432111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0132429000Medicaid
0576181Medicare ID - Type Unspecified
T32395Medicare UPIN