Provider Demographics
NPI:1639258643
Name:WUEBBEN, RYAN MATTHEW (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:WUEBBEN
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 1:25240 BALMORAL DR
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8371
Mailing Address - Country:US
Mailing Address - Phone:563-340-3337
Mailing Address - Fax:815-725-5722
Practice Address - Street 1:568 BROOK FOREST AVE.
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404
Practice Address - Country:US
Practice Address - Phone:815-725-5733
Practice Address - Fax:815-725-5722
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILZ04890Medicare UPIN
IL211598Medicare ID - Type Unspecified