Provider Demographics
NPI:1659690162
Name:WICKES, GENA MENZDORF (DC)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:MENZDORF
Last Name:WICKES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6424 CAMILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5439
Mailing Address - Country:US
Mailing Address - Phone:214-684-6863
Mailing Address - Fax:
Practice Address - Street 1:6424 CAMILLE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5439
Practice Address - Country:US
Practice Address - Phone:214-684-6863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11458111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor