Provider Demographics
NPI:1710004346
Name:KROLL, WESLEY VINTON (DC)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:VINTON
Last Name:KROLL
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 1:1 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-1331
Mailing Address - Country:US
Mailing Address - Phone:301-689-1200
Mailing Address - Fax:301-689-1200
Practice Address - Street 1:1 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1331
Practice Address - Country:US
Practice Address - Phone:301-689-1200
Practice Address - Fax:301-689-1200
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01885111N00000X
WV684111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD370937OtherMAMSI
MDM589WVOtherBCBS OF MARYLAND, INC.
MD370937OtherMAMSI
MDU71262Medicare UPIN