Provider Demographics
NPI:1699475863
Name:WILDE, SETH D (DC)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:D
Last Name:WILDE
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 1:3251 REDHAWK ST APT 305
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-8520
Mailing Address - Country:US
Mailing Address - Phone:602-904-2513
Mailing Address - Fax:
Practice Address - Street 1:555 W CHERRY ST STE 2
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9800
Practice Address - Country:US
Practice Address - Phone:319-626-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA118786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor