Provider Demographics
NPI:1992021737
Name:WICKSTROM, BRIAN CHRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:WICKSTROM
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 1:615 N SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8574
Mailing Address - Country:US
Mailing Address - Phone:509-342-9438
Mailing Address - Fax:
Practice Address - Street 1:615 N SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8574
Practice Address - Country:US
Practice Address - Phone:509-342-9438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.60139083111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor