| Doctor Name: | DR. BENNETT MICAH WYLLIE |
| NPI Number: | 1588001358 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 2013013255 |
| Business Practice Address: | 305 Nw Englewood Ct Suite 200 Gladstone, MO - 641184072 |
| Business Phone Number: | 8164545433 |
| Business Fax Number: | 8164548455 |
| Mailing Address: | 305 Nw Englewood Ct, Suite 200 GLADSTONE |
| State: | MO |
| Postal Code: | 641184072 |
| Phone Number: | 8164545433 |
| Fax Number: | 8164548455 |
| NPI Enumeration Date: | 06/03/2013 |
| NPI Last Update Date: | 06/03/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 2013013255 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |