Provider Demographics
NPI:1063585297
Name:WISE, STEPHEN ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALLEN
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 OAK HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1025
Mailing Address - Country:US
Mailing Address - Phone:419-332-9900
Mailing Address - Fax:419-332-3366
Practice Address - Street 1:1466 OAK HARBOR RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1025
Practice Address - Country:US
Practice Address - Phone:419-332-9900
Practice Address - Fax:419-332-3366
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4172721Medicare ID - Type Unspecified
V07195Medicare UPIN