Provider Demographics
NPI:1154356285
Name:WAKEFIELD, KRISTOPHER WADE (DC)
Entity type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:WADE
Last Name:WAKEFIELD
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 1:448 COLE ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:IL
Mailing Address - Zip Code:61422-1540
Mailing Address - Country:US
Mailing Address - Phone:309-772-2317
Mailing Address - Fax:309-772-2317
Practice Address - Street 1:448 COLE ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:IL
Practice Address - Zip Code:61422-1540
Practice Address - Country:US
Practice Address - Phone:309-772-2317
Practice Address - Fax:309-772-2317
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5522061OtherBC/BS NUMBER
IL5522061OtherBC/BS NUMBER
IL209655Medicare ID - Type UnspecifiedGROUP NUMBER
ILK09513Medicare ID - Type UnspecifiedPROVIDER NUMBER