Basic Information
| Provider Information | |||||||||
| NPI: | 1083201347 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILSON & ALLEN CHIROPRACTIC CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 W KETTLEMAN LN STE 104 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952424334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093346947 | ||||||||
| FaxNumber: | 2093346969 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W KETTLEMAN LN STE 104 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952424334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093346947 | ||||||||
| FaxNumber: | 2093346969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2020 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | SHERRI | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIROPRACTOR | ||||||||
| AuthorizedOfficialTelephone: | 2093346947 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 4379 | 01 | CA | CORPORATE CERTIFICATE | OTHER |