Healthcare Provider Details

I. General information

NPI: 1457410458
Provider Name (Legal Business Name): WILDER CHIROPRACTIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 EAGAN RD
MADISON WI
53704-3702
US

IV. Provider business mailing address

1702 EAGAN RD
MADISON WI
53704-3702
US

V. Phone/Fax

Practice location:
  • Phone: 608-243-1234
  • Fax: 608-243-3186
Mailing address:
  • Phone: 608-243-1234
  • Fax: 608-243-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1707
License Number StateWI

VIII. Authorized Official

Name: DR. JEFFREY M. WILDER
Title or Position: PRESIDENT
Credential: DC
Phone: 608-243-1234