Provider Demographics
NPI:1598965774
Name:DR. DAVID L. WICK, D.C., P.A.
Entity Type:Organization
Organization Name:DR. DAVID L. WICK, D.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:WICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-342-2083
Mailing Address - Street 1:105 NEW ENGLAND PLACE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6783
Mailing Address - Country:US
Mailing Address - Phone:651-342-2083
Mailing Address - Fax:651-342-2036
Practice Address - Street 1:105 NEW ENGLAND PLACE
Practice Address - Street 2:SUITE 250
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6783
Practice Address - Country:US
Practice Address - Phone:651-342-2083
Practice Address - Fax:651-342-2036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4578111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC09307Medicare UPIN