Provider Demographics
NPI:1649778937
Name:WILDERNESS WELLNESS CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:WILDERNESS WELLNESS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-481-7330
Mailing Address - Street 1:224 E CENTRAL ENTRANCE STE C
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5518
Mailing Address - Country:US
Mailing Address - Phone:218-481-7330
Mailing Address - Fax:218-481-7432
Practice Address - Street 1:224 E CENTRAL ENTRANCE STE C
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5518
Practice Address - Country:US
Practice Address - Phone:218-481-7330
Practice Address - Fax:218-481-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6436111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty