Provider Demographics
NPI:1821089780
Name:WENNEBORG, TIMOTHY L (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:L
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 1:1045 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3004
Mailing Address - Country:US
Mailing Address - Phone:207-544-5213
Mailing Address - Fax:217-544-8792
Practice Address - Street 1:1045 S 2ND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3004
Practice Address - Country:US
Practice Address - Phone:207-544-5213
Practice Address - Fax:217-544-8792
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
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
913520Medicare ID - Type Unspecified
T90469Medicare UPIN