Provider Demographics
NPI:1285694638
Name:WILTBANK, KENNETH L (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:WILTBANK
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 982
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-0982
Mailing Address - Country:US
Mailing Address - Phone:928-536-3235
Mailing Address - Fax:
Practice Address - Street 1:229 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5316
Practice Address - Country:US
Practice Address - Phone:928-536-3235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0239680OtherBLUE CROSS BLUE SHIELD
AZ350050540Medicaid
AZ5093OtherLICENCE NUMBER
AZ0239680OtherBLUE CROSS BLUE SHIELD
AZ5093OtherLICENCE NUMBER