Basic Information
| Provider Information | |||||||||
| NPI: | 1679548424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEBER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | A.T.C.,M.T.C.,L.P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1961 CARDINAL LN | ||||||||
| Address2: | STE A | ||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550214354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076452235 | ||||||||
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| Practice Location | |||||||||
| Address1: | 328 HERITAGE PL | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550215251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073332986 | ||||||||
| FaxNumber: | 5073332918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
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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 | 4148 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 644723600 | 05 | MN | MEDICAID |