Provider Demographics
NPI:1568590685
Name:WENNEBORG, RONALD CARTER (DC)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CARTER
Last Name:WENNEBORG
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 1:160 REDWING CT
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1083
Mailing Address - Country:US
Mailing Address - Phone:217-483-5215
Mailing Address - Fax:
Practice Address - Street 1:160 REDWING CT
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-1083
Practice Address - Country:US
Practice Address - Phone:217-483-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL658270Medicare PIN