Provider Demographics
NPI:1851951610
Name:KISSLING, WYATT RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:RICHARD
Last Name:KISSLING
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 1:26135 N 85TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3608
Mailing Address - Country:US
Mailing Address - Phone:602-903-8382
Mailing Address - Fax:
Practice Address - Street 1:26135 N 85TH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-3608
Practice Address - Country:US
Practice Address - Phone:602-903-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34569111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor