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NPI Code Detail

MEDICARE: DR. BENNETT MICAH WYLLIE

MEDICARE: DR. BENNETT MICAH WYLLIE
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
1111N00000XChiropractor2013013255MO

General Provider Information

NPI Number : 1588001358
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BENNETT MICAH WYLLIE
Provider Business Mailing Address
First Line : 305 NW ENGLEWOOD CT
Second Line : SUITE 200
City : GLADSTONE
State : MO
Zip : 64118-4072
Country : US
Telephone Number : 816-454-5433
Fax Number : 816-454-8455
Provider Business Practice Location Address
First Line : 305 NW ENGLEWOOD CT
Second Line : SUITE 200
City : GLADSTONE
State : MO
Zip : 64118-4072
Country : US
Telephone Number : 816-454-5433
Fax Number : 816-454-8455
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2013
Last Update Date : 06/03/2013

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Directions to “ DR. BENNETT MICAH WYLLIE ” Practice Location

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