Healthcare Provider Details

I. General information

NPI: 1679742662
Provider Name (Legal Business Name): CHARLENE ANN WEIDNER LIC.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 G 7/10 RD
PALISADE CO
81526-8733
US

IV. Provider business mailing address

3830 G 7/10 RD
PALISADE CO
81526-8733
US

V. Phone/Fax

Practice location:
  • Phone: 970-464-5413
  • Fax:
Mailing address:
  • Phone: 970-464-5413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number199
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: