MEDICARE: DR. GREGORY HAYLETT WEIDLICH D.C.

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	3432	OR

General Provider Information

NPI Number	:	1477849693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY HAYLETT WEIDLICH D.C.

Provider Business Mailing Address
First Line	:	PO BOX 1368
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-0536
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16869 65TH AVE # 356
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7865
Country	:	US
Telephone Number	:	503-336-1287
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	06/27/2011

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