Provider Demographics
NPI:1801080858
Name:WISE, ROBERT C II (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:WISE
Suffix:II
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 1:220 WOODWARD AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1757
Mailing Address - Country:US
Mailing Address - Phone:570-858-5436
Mailing Address - Fax:
Practice Address - Street 1:220 WOODWARD AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-1757
Practice Address - Country:US
Practice Address - Phone:570-858-5436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-003188-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor