Provider Demographics
NPI:1700361300
Name:WILCZAK, DANIEL GEORGE (DC, MSR)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GEORGE
Last Name:WILCZAK
Suffix:
Gender:M
Credentials:DC, MSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1274
Mailing Address - Country:US
Mailing Address - Phone:575-652-6433
Mailing Address - Fax:
Practice Address - Street 1:221 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1274
Practice Address - Country:US
Practice Address - Phone:575-652-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No175L00000XOther Service ProvidersHomeopath
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner