MEDICARE: ZACHARY WILDER

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	2255A2300X	Athletic Trainer	2018037623	MO
2	390200000X	Student in an Organized Health Care Education/Training Program
3	111N00000X	Chiropractor	038.013819	IL

General Provider Information

NPI Number	:	1346738762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY WILDER

Provider Business Mailing Address
First Line	:	260 E ARMY TRAIL RD STE D
Second Line	:
City	:	BARTLETT
State	:	IL
Zip	:	60103-3005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 S AVENUE B
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-3410
Country	:	US
Telephone Number	:	309-224-2021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	05/06/2022

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Directions to “ ZACHARY WILDER ” Practice Location

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