MEDICARE: DR MICHAEL WILD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1053933911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR MICHAEL WILD LLC

Provider Business Mailing Address
First Line	:	5528 RIVERSIDE HEIGHTS WAY
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-2477
Country	:	US
Telephone Number	:	804-651-2247
Fax Number	:

Provider Business Practice Location Address
First Line	:	10431 PATTERSON AVE
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23238-5101
Country	:	US
Telephone Number	:	804-651-2247
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL R WILD
Credential	:	DC
Telephone Number	:	804-651-2247

Provider Enumeration Date	:	05/14/2020
Last Update Date	:	05/14/2020

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