Healthcare Provider Details

I. General information

NPI: 1144788894
Provider Name (Legal Business Name): ALICE WEIDNER O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 AIRPORT RD
BARTO PA
19504-9054
US

IV. Provider business mailing address

120 AIRPORT RD
BARTO PA
19504-9054
US

V. Phone/Fax

Practice location:
  • Phone: 215-679-4554
  • Fax: 215-679-0500
Mailing address:
  • Phone: 215-679-4554
  • Fax: 215-679-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberOM000113
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierOM000113
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerORIENTAL MEDICINE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: