Provider Demographics
NPI:1285162123
Name:WIADRO, MICHAEL (LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIADRO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 SHEKEL LN
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-8958
Mailing Address - Country:US
Mailing Address - Phone:610-389-8422
Mailing Address - Fax:
Practice Address - Street 1:424 S RIDGE ST
Practice Address - Street 2:STE 3
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424
Practice Address - Country:US
Practice Address - Phone:610-389-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02108171100000X
CO2579171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty