Provider Demographics
NPI:1912054677
Name:DE WILD CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:DE WILD CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RANEE
Authorized Official - Last Name:DEWILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-282-3900
Mailing Address - Street 1:930 W MARKET ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1006
Mailing Address - Country:US
Mailing Address - Phone:618-282-3900
Mailing Address - Fax:618-282-3971
Practice Address - Street 1:930 W MARKET ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1006
Practice Address - Country:US
Practice Address - Phone:618-282-3900
Practice Address - Fax:618-282-3971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7932010OtherBCBS
IL671268OtherUHC
IL671268OtherUHC