Provider Demographics
NPI:1649373606
Name:WIEBURG, KIM ANNETTE (DC)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:ANNETTE
Last Name:WIEBURG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:2134 FRANCESCO CIR
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2075
Mailing Address - Country:US
Mailing Address - Phone:831-247-9842
Mailing Address - Fax:831-479-3239
Practice Address - Street 1:555 SOQUEL AVE
Practice Address - Street 2:STE. 260
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2336
Practice Address - Country:US
Practice Address - Phone:831-247-9842
Practice Address - Fax:831-479-3239
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18694111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0186940Medicare UPIN