Healthcare Provider Details

I. General information

NPI: 1023137585
Provider Name (Legal Business Name): KENNETH LEON WECKER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23440 SE STARK ST
GRESHAM OR
97030-2961
US

IV. Provider business mailing address

23440 SE STARK ST
GRESHAM OR
97030-2961
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-6245
  • Fax: 503-489-0552
Mailing address:
  • Phone: 503-489-6245
  • Fax: 503-489-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number713726
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: