=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134135544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM WIEBKE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5516 MERRICK RD
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11758-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-799-6696
-----------------------------------------------------
Fax | 516-799-2877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 HENRY RD
-----------------------------------------------------
City | N MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-2335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-799-6696
-----------------------------------------------------
Fax | 516-799-2877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X007754
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------