Provider Demographics
NPI:1528123130
Name:WILEY, JERALD DALE (DC)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:DALE
Last Name:WILEY
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 363
Mailing Address - Street 2:
Mailing Address - City:VAUGHN
Mailing Address - State:MT
Mailing Address - Zip Code:59487
Mailing Address - Country:US
Mailing Address - Phone:406-727-5757
Mailing Address - Fax:406-727-7006
Practice Address - Street 1:1520 3RD ST NW
Practice Address - Street 2:SUITE E
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404
Practice Address - Country:US
Practice Address - Phone:406-727-5757
Practice Address - Fax:406-727-7006
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT00040903OtherBLUE CROSS BLUE SHIELD
MT004618Medicare ID - Type Unspecified