Healthcare Provider Details

I. General information

NPI: 1346738762
Provider Name (Legal Business Name): ZACHARY WILDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S AVENUE B
CANTON IL
61520-3410
US

IV. Provider business mailing address

260 E ARMY TRAIL RD STE D
BARTLETT IL
60103-3005
US

V. Phone/Fax

Practice location:
  • Phone: 309-224-2021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.013819
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2018037623
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: