MEDICARE: DR. DAVID CHRISTIAN WIENCKE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1729	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	59153WI	OTHER	MN	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1013091230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID CHRISTIAN WIENCKE D.C.

Provider Business Mailing Address
First Line	:	550 40TH AVE. NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421
Country	:	US
Telephone Number	:	763-788-9797
Fax Number	:	763-788-9541

Provider Business Practice Location Address
First Line	:	550 40TH AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-3835
Country	:	US
Telephone Number	:	763-788-9797
Fax Number	:	763-788-9541

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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