Provider Demographics
NPI:1841395027
Name:WILCOX, RANDAL IRVING (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:IRVING
Last Name:WILCOX
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 1:935 52ND ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6003
Mailing Address - Country:US
Mailing Address - Phone:616-531-1500
Mailing Address - Fax:616-531-2881
Practice Address - Street 1:935 52ND ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-6003
Practice Address - Country:US
Practice Address - Phone:616-531-1500
Practice Address - Fax:616-531-2881
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004706111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U36455Medicare UPIN
MIOP16110Medicare ID - Type Unspecified