Provider Demographics
NPI:1972839645
Name:WICKSTROM, BRET
Entity Type:Individual
Prefix:DR
First Name:BRET
Middle Name:
Last Name:WICKSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 E 10TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-0838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4320 E 10TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-0838
Practice Address - Country:US
Practice Address - Phone:252-758-7583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4026111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor