Provider Demographics
NPI:1487461547
Name:WILDERMUTH, RICHARD ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
Last Name:WILDERMUTH
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 1:120 HICKORY FLAT HWY
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:678-880-6616
Mailing Address - Fax:
Practice Address - Street 1:120 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:678-880-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR011200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor