Provider Demographics
NPI:1093268336
Name:WIENEKE, MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIENEKE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 HENRIETTA AVE E
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-3141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:437 CAMBRIDGE AVE E
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2244
Practice Address - Country:US
Practice Address - Phone:864-223-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3034225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant