Provider Demographics
NPI:1760465439
Name:HUDDLESTON, WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:HUDDLESTON
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 1:2100 E BROADWAY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6082
Mailing Address - Country:US
Mailing Address - Phone:573-499-0449
Mailing Address - Fax:573-499-0449
Practice Address - Street 1:2100 E BROADWAY
Practice Address - Street 2:SUITE 308
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6082
Practice Address - Country:US
Practice Address - Phone:573-499-0449
Practice Address - Fax:573-499-0449
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE6401111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU58846Medicare UPIN
MO31517Medicare ID - Type Unspecified