Provider Demographics
NPI:1689607822
Name:WICKWIRE, BONNIE LEIGH (DC / ND)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LEIGH
Last Name:WICKWIRE
Suffix:
Gender:F
Credentials:DC / ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5124
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:541-426-6403
Practice Address - Street 1:507 S RIVER ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1601
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2277111N00000X
OR0862175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No111N00000XChiropractic ProvidersChiropractor