Provider Demographics
NPI:1770515934
Name:WILDE, LARRY G (DC)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:G
Last Name:WILDE
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 1:219 E 1550 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-9003
Mailing Address - Country:US
Mailing Address - Phone:801-785-6784
Mailing Address - Fax:
Practice Address - Street 1:246 S 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2829
Practice Address - Country:US
Practice Address - Phone:890-175-6883
Practice Address - Fax:801-756-9014
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT290149-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor