Healthcare Provider Details

I. General information

NPI: 1831246990
Provider Name (Legal Business Name): WILD CHIROPRACTIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 MAIN STREET
SEWARD NE
68434-2072
US

IV. Provider business mailing address

905 MAIN ST
SEWARD NE
68434-2047
US

V. Phone/Fax

Practice location:
  • Phone: 402-643-6565
  • Fax: 402-643-6565
Mailing address:
  • Phone: 402-643-6565
  • Fax: 402-643-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1017
License Number StateNE

VIII. Authorized Official

Name: DR. JOHN ANDREW WILD
Title or Position: CHIROPRACTOR OWNER
Credential: D.C.
Phone: 402-643-6565