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General NPI Number Information
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NPI Number | 1649778937
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Entity Type | Organization
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Legal Business Name | WILDERNESS WELLNESS CHIROPRACTIC LLC
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Dates
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Enumeration Date | 02/01/2018
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Last Update Date | 02/01/2018
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Provider Practice Location Address
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Address Line | 224 E CENTRAL ENTRANCE STE C
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City | DULUTH
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State | MN
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Zip | 55811-5518
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Country | US
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Telephone | 218-481-7330
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Fax | 218-481-7432
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Provider Business Mailing Address
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Address Line | 224 E CENTRAL ENTRANCE STE C
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City | DULUTH
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State | MN
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Zip | 55811-5518
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Country | US
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Telephone | 218-481-7330
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Fax | 218-481-7432
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Authorized Official
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Title or Position | CHIEF MANAGER
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Name | DR. KYLE SEVERSON
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Credential | DC
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Telephone | 218-481-7330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 6436
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License Number State | MN
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