Provider Demographics
NPI:1215972963
Name:WIEBE, KERRY DANIEL (DC)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:DANIEL
Last Name:WIEBE
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 1:131 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3626
Mailing Address - Country:US
Mailing Address - Phone:802-878-4946
Mailing Address - Fax:802-878-9625
Practice Address - Street 1:131 PEARL ST
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3626
Practice Address - Country:US
Practice Address - Phone:802-878-4946
Practice Address - Fax:802-878-9625
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-00001086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTWI VN 2683Medicare PIN
VTU86699Medicare UPIN