=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649653429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID WENZEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2015
-----------------------------------------------------
Last Update Date | 06/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9249 W LAKE CITY RD
-----------------------------------------------------
City | HOUGHTON LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48629-9602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-422-2115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2260 MANCHESTER DR
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48609-9221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-798-4252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501017200
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------