Provider Demographics
NPI:1336817097
Name:WILSON, KALEB JOE (DC)
Entity Type:Individual
Prefix:DR
First Name:KALEB
Middle Name:JOE
Last Name:WILSON
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 1:1713 FORT JESSE RD STE D
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6235
Mailing Address - Country:US
Mailing Address - Phone:309-862-2225
Mailing Address - Fax:
Practice Address - Street 1:1713 FORT JESSE RD STE D
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6235
Practice Address - Country:US
Practice Address - Phone:309-862-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor