Provider Demographics
NPI:1205940954
Name:RUSTICI, WADE (DC)
Entity type:Individual
Prefix:DR
First Name:WADE
Middle Name:
Last Name:RUSTICI
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 1:2307 NW SOUTH OUTER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-1712
Mailing Address - Country:US
Mailing Address - Phone:816-745-4532
Mailing Address - Fax:816-295-9909
Practice Address - Street 1:2307 NW SOUTH OUTER RD STE 101
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-1712
Practice Address - Country:US
Practice Address - Phone:816-745-4532
Practice Address - Fax:816-295-9909
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161199111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO483443Medicare UPIN