Provider Demographics
NPI:1295822625
Name:MARK WIEGAND DC SC
Entity Type:Organization
Organization Name:MARK WIEGAND DC SC
Other - Org Name:FAMILY CHIROPRACTIC & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:WIEGAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-222-5100
Mailing Address - Street 1:926 BROADWAY ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2748
Mailing Address - Country:US
Mailing Address - Phone:217-222-5100
Mailing Address - Fax:217-222-5178
Practice Address - Street 1:926 BROADWAY ST
Practice Address - Street 2:SUITE 4
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2748
Practice Address - Country:US
Practice Address - Phone:217-222-5100
Practice Address - Fax:217-222-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU88488Medicare UPIN
IL209273Medicare ID - Type Unspecified