Provider Demographics
NPI:1891794293
Name:WIENER, GABRIEL L (DC)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:L
Last Name:WIENER
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 1:104 JOHNSON AVE N
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1328
Mailing Address - Country:US
Mailing Address - Phone:218-435-6186
Mailing Address - Fax:218-435-6181
Practice Address - Street 1:104 JOHNSON AVE N
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1328
Practice Address - Country:US
Practice Address - Phone:218-435-6186
Practice Address - Fax:218-435-6181
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U94902Medicare UPIN