Provider Demographics
NPI:1730657230
Name:BRICE WILTGEN D.C., PLLC
Entity Type:Organization
Organization Name:BRICE WILTGEN D.C., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILTGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:308-440-9821
Mailing Address - Street 1:15288 W BROOKSIDE LN STE 139
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-3990
Mailing Address - Country:US
Mailing Address - Phone:623-544-4444
Mailing Address - Fax:
Practice Address - Street 1:15288 W BROOKSIDE LN STE 139
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3990
Practice Address - Country:US
Practice Address - Phone:623-544-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service