Provider Demographics
NPI:1538297494
Name:WICKS, TYLER RHEA (DC)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:RHEA
Last Name:WICKS
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 1:2003 W BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1111
Mailing Address - Country:US
Mailing Address - Phone:573-442-2060
Mailing Address - Fax:573-564-4290
Practice Address - Street 1:2003 W BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1111
Practice Address - Country:US
Practice Address - Phone:573-442-2060
Practice Address - Fax:573-564-4290
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006035965111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor