Provider Demographics
NPI:1144639931
Name:WIERENGA, JUSTIN (ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WIERENGA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 14TH ST NE
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-6413
Mailing Address - Country:US
Mailing Address - Phone:616-706-1465
Mailing Address - Fax:
Practice Address - Street 1:620 MICHIGAN AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20064-0001
Practice Address - Country:US
Practice Address - Phone:202-319-6049
Practice Address - Fax:202-319-4752
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer