Provider Demographics
NPI:1972711885
Name:WIEGAND, TRACY RUST (DC)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:RUST
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DOVER DR
Mailing Address - Street 2:SUITE #1
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-5735
Mailing Address - Country:US
Mailing Address - Phone:949-645-2400
Mailing Address - Fax:
Practice Address - Street 1:601 DOVER DR
Practice Address - Street 2:SUITE #1
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-5735
Practice Address - Country:US
Practice Address - Phone:949-645-2400
Practice Address - Fax:949-645-2060
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-27522111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor