Provider Demographics
NPI:1306441985
Name:WILCOX, KIERSTEN MARIAH (DC)
Entity type:Individual
Prefix:DR
First Name:KIERSTEN
Middle Name:MARIAH
Last Name:WILCOX
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 S WALNUT ST LOT 12
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43103-1079
Mailing Address - Country:US
Mailing Address - Phone:419-302-7240
Mailing Address - Fax:
Practice Address - Street 1:3368 STATE ROUTE 752
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43103-9009
Practice Address - Country:US
Practice Address - Phone:740-983-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05019111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH05019Medicaid