Provider Demographics
NPI:1972507937
Name:RODOCKER-WIARDA, KERRY ANN (DC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ANN
Last Name:RODOCKER-WIARDA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ANN
Other - Last Name:RODOCKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:5912 SPENCER HWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-1602
Mailing Address - Country:US
Mailing Address - Phone:281-998-6140
Mailing Address - Fax:281-998-0558
Practice Address - Street 1:5912 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-1602
Practice Address - Country:US
Practice Address - Phone:281-998-6140
Practice Address - Fax:281-998-0558
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251029-00Medicaid
NE09644OtherBC/BS
NE10025102900Medicaid
277410Medicare PIN
U89459Medicare UPIN
NE100251029-00Medicaid
NEU89459Medicare UPIN
NE09644OtherBC/BS