Provider Demographics
NPI:1316685670
Name:WILDER, GARRETT LEO (DC)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:LEO
Last Name:WILDER
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 1:9888 W 231ST ST
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:KS
Mailing Address - Zip Code:66013-9262
Mailing Address - Country:US
Mailing Address - Phone:913-850-4532
Mailing Address - Fax:
Practice Address - Street 1:11709 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1398
Practice Address - Country:US
Practice Address - Phone:913-228-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-06192111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor