Provider Demographics
NPI:1770769507
Name:WIMMER, MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIMMER
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 1:413 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-6320
Mailing Address - Country:US
Mailing Address - Phone:801-399-5697
Mailing Address - Fax:801-399-5699
Practice Address - Street 1:413 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-6320
Practice Address - Country:US
Practice Address - Phone:801-399-5697
Practice Address - Fax:801-399-5699
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT167047-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T78065Medicare UPIN