Provider Demographics
NPI:1871641993
Name:WICKWIRE, KIM ARTHUR (DC)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:ARTHUR
Last Name:WICKWIRE
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 1:3706 N FABER AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-7614
Mailing Address - Country:US
Mailing Address - Phone:309-685-6910
Mailing Address - Fax:309-685-7313
Practice Address - Street 1:3706 N FABER AVE
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-7614
Practice Address - Country:US
Practice Address - Phone:309-685-6910
Practice Address - Fax:309-685-7313
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37386Medicare UPIN
IL640920Medicare ID - Type Unspecified