Provider Demographics
NPI:1730192162
Name:WILSON, KENDALL LEVELL (DC)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:LEVELL
Last Name:WILSON
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 3554
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-3554
Mailing Address - Country:US
Mailing Address - Phone:501-658-9000
Mailing Address - Fax:501-280-0260
Practice Address - Street 1:1200 BARROW RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6500
Practice Address - Country:US
Practice Address - Phone:501-838-5429
Practice Address - Fax:501-421-0191
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1681OtherSTATE LICENSE