Healthcare Provider Details

I. General information

NPI: 1720499858
Provider Name (Legal Business Name): ANDREA WICK D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 SNOWY MOUNTAIN CIRCLE
BIG SKY MT
59716-1131
US

IV. Provider business mailing address

PO BOX 161131
BIG SKY MT
59716-1131
US

V. Phone/Fax

Practice location:
  • Phone: 262-893-8316
  • Fax:
Mailing address:
  • Phone: 262-893-8316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2376
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2376
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: