Provider Demographics
NPI:1356378848
Name:WIEDRICH, KEITH ALLEN (ATC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALLEN
Last Name:WIEDRICH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 7TH ST N
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1570
Mailing Address - Country:US
Mailing Address - Phone:218-287-8402
Mailing Address - Fax:
Practice Address - Street 1:1107 7TH ST. S.
Practice Address - Street 2:MSU MOORHEAD - ATHLETICS
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563
Practice Address - Country:US
Practice Address - Phone:218-477-2626
Practice Address - Fax:218-477-5943
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer