Provider Demographics
NPI:1154521334
Name:WICK, DAVID LESLIE (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LESLIE
Last Name:WICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:105 NEW ENGLAND PLACE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6783
Mailing Address - Country:US
Mailing Address - Phone:651-342-2083
Mailing Address - Fax:651-342-2036
Practice Address - Street 1:105 NEW ENGLAND PLACE
Practice Address - Street 2:SUITE 250
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6783
Practice Address - Country:US
Practice Address - Phone:651-342-2083
Practice Address - Fax:651-342-2036
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2014-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN4578111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350005225Medicare PIN