Provider Demographics
NPI:1013091230
Name:WIENCKE, DAVID CHRISTIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHRISTIAN
Last Name:WIENCKE
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 1:550 40TH AVE. NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421
Mailing Address - Country:US
Mailing Address - Phone:763-788-9797
Mailing Address - Fax:763-788-9541
Practice Address - Street 1:550 40TH AVE NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-3835
Practice Address - Country:US
Practice Address - Phone:763-788-9797
Practice Address - Fax:763-788-9541
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN59153WIOtherBLUE CROSS BLUE SHEILD
MN59153WIOtherBLUE CROSS BLUE SHEILD