MEDICARE: WIERSIG CHIROPRACTIC CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3048	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	443545904001	OTHER	OK	BLUE CROSS

General Provider Information

NPI Number	:	1043405772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIERSIG CHIROPRACTIC CLINIC

Provider Business Mailing Address
First Line	:	2013 S AIR DEPOT BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-5523
Country	:	US
Telephone Number	:	405-737-5653
Fax Number	:	405-733-5656

Provider Business Practice Location Address
First Line	:	2013 S AIR DEPOT BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73110-5523
Country	:	US
Telephone Number	:	405-737-5653
Fax Number	:	405-733-5656

Authorized Official
Title or Position	:	OWNER
Name	:	RICKY D WIERSIG
Credential	:	D.C.
Telephone Number	:	405-737-5653

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	09/06/2007

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