Provider Demographics
NPI:1063435733
Name:WIEKING, KIM EMRIN (PT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:EMRIN
Last Name:WIEKING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 E. 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-334-6730
Mailing Address - Fax:605-444-8431
Practice Address - Street 1:7600 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2985
Practice Address - Country:US
Practice Address - Phone:605-444-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN802927000Medicaid
SD5830302Medicaid
IA0580068Medicaid
SD4995624OtherBCBS
SD5830302Medicaid
MN802927000Medicaid