Provider Demographics
NPI:1861821605
Name:WYLIE ENTERPRISES, INC
Entity Type:Organization
Organization Name:WYLIE ENTERPRISES, INC
Other - Org Name:PROVIDENCE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-801-7227
Mailing Address - Street 1:100 PROVIDENCE MAIN ST NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-4826
Mailing Address - Country:US
Mailing Address - Phone:256-801-7227
Mailing Address - Fax:256-361-9942
Practice Address - Street 1:100 PROVIDENCE MAIN ST NW
Practice Address - Street 2:SUITE D
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-4826
Practice Address - Country:US
Practice Address - Phone:256-801-7227
Practice Address - Fax:256-361-9942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty