Provider Demographics
NPI:1619782778
Name:WIECZOREK, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:WIECZOREK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5030
Mailing Address - Country:US
Mailing Address - Phone:308-390-8386
Mailing Address - Fax:
Practice Address - Street 1:1801 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-5030
Practice Address - Country:US
Practice Address - Phone:308-390-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372500000XNursing Service Related ProvidersChore Provider