Provider Demographics
NPI:1467572628
Name:WIEDRICH, NATHAN EVAN (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:EVAN
Last Name:WIEDRICH
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 1:2031 E GRAND AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9094
Mailing Address - Country:US
Mailing Address - Phone:843-906-0090
Mailing Address - Fax:
Practice Address - Street 1:2031 E GRAND AVE STE 301
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-9094
Practice Address - Country:US
Practice Address - Phone:843-906-0090
Practice Address - Fax:843-906-0090
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3342111N00000X
IL3801096111N00000X
IL038.010896111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor