Provider Demographics
NPI:1407148554
Name:WISETH, STEVEN RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RICHARD
Last Name:WISETH
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 1:205 BROOKS AVE N
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-1724
Mailing Address - Country:US
Mailing Address - Phone:218-689-2885
Mailing Address - Fax:
Practice Address - Street 1:205 BROOKS AVE N
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-1724
Practice Address - Country:US
Practice Address - Phone:218-689-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5506111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor