Provider Demographics
NPI:1679645006
Name:WILD, DANIEL K (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:K
Last Name:WILD
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 1:240 SCHOOLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1146
Mailing Address - Country:US
Mailing Address - Phone:989-386-3400
Mailing Address - Fax:989-386-4878
Practice Address - Street 1:240 SCHOOLCREST AVE
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1146
Practice Address - Country:US
Practice Address - Phone:989-386-3400
Practice Address - Fax:989-386-4878
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006627111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1893563Medicaid
MI950C75001OtherBCBS
MI0C75001Medicare ID - Type Unspecified
MI1893563Medicaid