Provider Demographics
NPI:1578562914
Name:WEIDLICH, TROY R (DC)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:R
Last Name:WEIDLICH
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 1:22023 STATE ROAD 7
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-3401
Mailing Address - Country:US
Mailing Address - Phone:561-477-8081
Mailing Address - Fax:561-477-9280
Practice Address - Street 1:22023 STATE ROAD 7
Practice Address - Street 2:SUITE 101
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-3401
Practice Address - Country:US
Practice Address - Phone:561-477-8081
Practice Address - Fax:561-477-9280
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6095111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
22956OtherBCBS
D70707Medicare UPIN
22956OtherBCBS