Healthcare Provider Details

I. General information

NPI: 1700780343
Provider Name (Legal Business Name): FREDERICK WIEDEN III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S SCHWARTZ AVE
FARMINGTON NM
87401-5955
US

IV. Provider business mailing address

PO BOX 869
MORRO BAY CA
93443-0869
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-2625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: