Healthcare Provider Details

I. General information

NPI: 1760814321
Provider Name (Legal Business Name): MR. ROBERT LOUIS WIEDLING JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 N MILL ST
PLYMOUTH MI
48170-2189
US

IV. Provider business mailing address

15255 PEBBLEBROOK DR
BELLEVILLE MI
48111-5235
US

V. Phone/Fax

Practice location:
  • Phone: 734-416-5200
  • Fax:
Mailing address:
  • Phone: 734-645-4294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: