Provider Demographics
NPI:1023062494
Name:WILCOX, RONALD DALE (DC)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DALE
Last Name:WILCOX
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 1:204 PINEHURST DR SW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4500
Mailing Address - Country:US
Mailing Address - Phone:360-352-8112
Mailing Address - Fax:360-352-8113
Practice Address - Street 1:204 PINEHURST DR SW
Practice Address - Street 2:SUITE 103
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4500
Practice Address - Country:US
Practice Address - Phone:360-352-8112
Practice Address - Fax:360-352-8113
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002441111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU11462Medicare UPIN
WAG001002046Medicare ID - Type Unspecified