Provider Demographics
NPI:1659566974
Name:CHIROPRACTIC WELLNESS CENTER, P.C.
Entity Type:Organization
Organization Name:CHIROPRACTIC WELLNESS CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:MAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-682-4000
Mailing Address - Street 1:404 S DOUGLAS HWY
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4029
Mailing Address - Country:US
Mailing Address - Phone:307-682-4000
Mailing Address - Fax:307-686-0768
Practice Address - Street 1:404 S DOUGLAS HWY
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4029
Practice Address - Country:US
Practice Address - Phone:307-682-4000
Practice Address - Fax:307-686-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY586 WY261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9963Medicare PIN