Healthcare Provider Details

I. General information

NPI: 1659566974
Provider Name (Legal Business Name): CHIROPRACTIC WELLNESS CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 S DOUGLAS HWY
GILLETTE WY
82716-4029
US

IV. Provider business mailing address

404 S DOUGLAS HWY
GILLETTE WY
82716-4029
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-4000
  • Fax: 307-686-0768
Mailing address:
  • Phone: 307-682-4000
  • Fax: 307-686-0768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number586 WY
License Number StateWY

VIII. Authorized Official

Name: MISS KIRSTEN KIM MAYCOCK
Title or Position: PRESIDENT
Credential: D.C.
Phone: 307-682-4000