Provider Demographics
NPI:1902970312
Name:WICKLUND, ELLEN LUCILLE (DC)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:LUCILLE
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MAIN ST SW
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864
Mailing Address - Country:US
Mailing Address - Phone:406-676-0170
Mailing Address - Fax:406-676-0160
Practice Address - Street 1:206 MAIN ST SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864
Practice Address - Country:US
Practice Address - Phone:406-676-0170
Practice Address - Fax:406-676-0160
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1050111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00067474OtherRR MEDICARE
40743OtherBCBS
U94657Medicare UPIN