Provider Demographics
NPI:1043603574
Name:FEDERSPIEL, WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:
Last Name:FEDERSPIEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 FARMINGTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1511
Mailing Address - Country:US
Mailing Address - Phone:616-915-4416
Mailing Address - Fax:
Practice Address - Street 1:1027 FARMINGTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1511
Practice Address - Country:US
Practice Address - Phone:616-915-4416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1932111N00000X
CT001932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty