Healthcare Provider Details

I. General information

NPI: 1679622716
Provider Name (Legal Business Name): RICHARD LOREN WILCOX D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1958 E VINEYARD ST
WAILUKU HI
96793-1715
US

IV. Provider business mailing address

1958 E VINEYARD ST
WAILUKU HI
96793-1715
US

V. Phone/Fax

Practice location:
  • Phone: 808-871-6996
  • Fax: 808-893-0866
Mailing address:
  • Phone: 808-871-6996
  • Fax: 808-893-0866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC 384
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: