Provider Demographics
NPI:1063741015
Name:VANDER WIELEN HEALTH & WELLNESS DIAGNOSTIC CENTER, LLC
Entity type:Organization
Organization Name:VANDER WIELEN HEALTH & WELLNESS DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:VANDER WIELEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-722-2100
Mailing Address - Street 1:1486 KENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1133
Mailing Address - Country:US
Mailing Address - Phone:920-722-2100
Mailing Address - Fax:920-722-2101
Practice Address - Street 1:1486 KENWOOD DR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1133
Practice Address - Country:US
Practice Address - Phone:920-722-2100
Practice Address - Fax:920-722-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty