Provider Demographics
NPI:1952933210
Name:WEYENBERG, JEFFREY C
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:WEYENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E9321 CRAIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-8520
Mailing Address - Country:US
Mailing Address - Phone:920-716-4694
Mailing Address - Fax:920-716-9020
Practice Address - Street 1:E9321 CRAIN RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-8520
Practice Address - Country:US
Practice Address - Phone:920-716-4694
Practice Address - Fax:920-716-9020
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)