Provider Demographics
NPI:1346414950
Name:WIEDRICH LLC
Entity Type:Organization
Organization Name:WIEDRICH LLC
Other - Org Name:HEALTHSOURCE OF JAMES ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORI
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WIEDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-906-7232
Mailing Address - Street 1:1175 FOLLY RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4130
Mailing Address - Country:US
Mailing Address - Phone:843-225-1236
Mailing Address - Fax:843-225-1237
Practice Address - Street 1:1175 FOLLY RD
Practice Address - Street 2:SUITE E
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-4130
Practice Address - Country:US
Practice Address - Phone:843-225-1236
Practice Address - Fax:843-225-1237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty