Provider Demographics
NPI:1326122193
Name:WEDDELL, GARY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:WEDDELL
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 1:1140 MANGROVE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3500
Mailing Address - Country:US
Mailing Address - Phone:530-345-3043
Mailing Address - Fax:530-345-2104
Practice Address - Street 1:1140 MANGROVE AVE STE C
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3500
Practice Address - Country:US
Practice Address - Phone:530-345-3043
Practice Address - Fax:530-345-2104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15066111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0150660Medicare UPIN