Provider Demographics
NPI:1972000271
Name:WILDE, COLT WYATT (DC)
Entity Type:Individual
Prefix:DR
First Name:COLT
Middle Name:WYATT
Last Name:WILDE
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 1:3410 W WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1590
Mailing Address - Country:US
Mailing Address - Phone:336-274-3500
Mailing Address - Fax:
Practice Address - Street 1:3410 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1590
Practice Address - Country:US
Practice Address - Phone:336-274-3500
Practice Address - Fax:336-292-1928
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor