Provider Demographics
NPI:1194895748
Name:WILDE, BRADLEY R (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:WILDE
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:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-0017
Mailing Address - Country:US
Mailing Address - Phone:307-431-5683
Mailing Address - Fax:
Practice Address - Street 1:801 ROBERTSON AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-2717
Practice Address - Country:US
Practice Address - Phone:307-347-4224
Practice Address - Fax:307-347-4240
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY379111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW308080Medicare ID - Type UnspecifiedMEDICARE
WY830326830Medicare UPIN