Basic Information
| Provider Information | |||||||||
| NPI: | 1619416708 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEHE | ||||||||
| FirstName: | CRAIG | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282092290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232248 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15825 BALLANTYNE MEDICAL PL STE 120 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282774790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043233409 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2017 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P19180 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.