Provider Demographics
NPI:1548344765
Name:WICKWARE, CHARLES ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:WICKWARE
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 1:144 FAIRWAY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6455
Mailing Address - Country:US
Mailing Address - Phone:830-792-4663
Mailing Address - Fax:830-896-8161
Practice Address - Street 1:144 FAIRWAY DR
Practice Address - Street 2:SUITE D
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6455
Practice Address - Country:US
Practice Address - Phone:830-792-4663
Practice Address - Fax:830-896-8161
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5612111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1094575-02Medicaid
TX84201-BCBSOtherBLUE CROSS
TX350028968OtherMEDICARE RR
TX84K201Medicare PIN
TXU12076Medicare UPIN
TX84K201-00G41GMedicare ID - Type UnspecifiedMEDICARE