Provider Demographics
NPI:1487685574
Name:WECKBACHER, GARY T (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:T
Last Name:WECKBACHER
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 1:2048 MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1605
Mailing Address - Country:US
Mailing Address - Phone:818-957-7612
Mailing Address - Fax:818-957-3756
Practice Address - Street 1:2048 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1605
Practice Address - Country:US
Practice Address - Phone:818-957-7612
Practice Address - Fax:818-957-3756
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18169111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT06635Medicare UPIN