Provider Demographics
NPI:1104226455
Name:WICKEY, SPENCER
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:WICKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N ELECTRIC CT
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1858
Mailing Address - Country:US
Mailing Address - Phone:269-651-6527
Mailing Address - Fax:
Practice Address - Street 1:208 W CHICAGO RD
Practice Address - Street 2:SUITE 9B
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1779
Practice Address - Country:US
Practice Address - Phone:269-651-6527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-23
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010213111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor