Provider Demographics
NPI:1619072535
Name:WIEST, TRACEY S (DC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:WIEST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2093 N COLLINS BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-8302
Mailing Address - Country:US
Mailing Address - Phone:972-231-4231
Mailing Address - Fax:972-907-8900
Practice Address - Street 1:2093 N COLLINS BLVD
Practice Address - Street 2:STE 105
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-8301
Practice Address - Country:US
Practice Address - Phone:972-231-4231
Practice Address - Fax:972-907-8900
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83Y028OtherBLUE CROSS BLUE SHIELD
TX83Y028OtherBLUE CROSS BLUE SHIELD