Provider Demographics
NPI:1073745832
Name:VANDER WIELEN, SCOTT MARTIN (DC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MARTIN
Last Name:VANDER WIELEN
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 1:1486 KENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1133
Mailing Address - Country:US
Mailing Address - Phone:920-722-2100
Mailing Address - Fax:920-722-2101
Practice Address - Street 1:1486 KENWOOD DR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1133
Practice Address - Country:US
Practice Address - Phone:920-722-2100
Practice Address - Fax:920-722-2100
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4565-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor