Healthcare Provider Details

I. General information

NPI: 1407956261
Provider Name (Legal Business Name): TERRY L. WILEY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 MAIN ST., SUITE #6
ALAMOSA CO
81101-2664
US

IV. Provider business mailing address

511 MAIN ST STE 6
ALAMOSA CO
81101-2649
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-5163
  • Fax: 719-589-8988
Mailing address:
  • Phone: 719-589-5163
  • Fax: 719-589-8988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number1181
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: