Provider Demographics
NPI:1205046372
Name:WIEDER, JUNE LESLIE (DC)
Entity type:Individual
Prefix:MISS
First Name:JUNE
Middle Name:LESLIE
Last Name:WIEDER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 S GOLD CANYON ST
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-4121
Mailing Address - Country:US
Mailing Address - Phone:760-375-7771
Mailing Address - Fax:760-495-9463
Practice Address - Street 1:131 S GOLD CANYON ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-4121
Practice Address - Country:US
Practice Address - Phone:760-375-7771
Practice Address - Fax:760-495-9463
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0237070111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC023707Medicare ID - Type UnspecifiedMEDICARE TID