Provider Demographics
NPI:1518396936
Name:KINGSBURY, RICHARD WOLCOTT (DC, LAT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WOLCOTT
Last Name:KINGSBURY
Suffix:
Gender:M
Credentials:DC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 VAN HECKE AVE
Mailing Address - Street 2:APT 38
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-9295
Mailing Address - Country:US
Mailing Address - Phone:815-762-3155
Mailing Address - Fax:
Practice Address - Street 1:721 CARDINAL LN
Practice Address - Street 2:SUITE 100
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-3216
Practice Address - Country:US
Practice Address - Phone:920-434-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4972-12111N00000X
WI1436-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer