Provider Demographics
NPI:1194784140
Name:WISE, NICHOLAS ALEXANDER (DC)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ALEXANDER
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 1:1400 FERNWOOD GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-3043
Mailing Address - Country:US
Mailing Address - Phone:864-585-5558
Mailing Address - Fax:864-585-9888
Practice Address - Street 1:1400 FERNWOOD GLENDALE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-3043
Practice Address - Country:US
Practice Address - Phone:864-585-5558
Practice Address - Fax:864-585-9888
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2549111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2549Medicaid
SCCH2549Medicaid