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General NPI Number Information
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NPI Number | 1376258467
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Entity Type | Organization
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Legal Business Name | ELDERBERRY HEALTH FOUNDATION
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Dates
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Enumeration Date | 01/23/2023
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Last Update Date | 01/23/2023
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Provider Practice Location Address
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Address Line | 1207 DELAWARE AVE #1904
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City | WILMINGTON
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State | DE
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Zip | 19806
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Country | US
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Telephone | 314-788-4620
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Fax |
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Provider Business Mailing Address
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Address Line | 15455 MANCHESTER RD #3313
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City | BALLWIN
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State | MO
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Zip | 63022-5049
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. LANDON WIEDENMAN
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Credential |
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Telephone | 314-788-4620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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