Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | DC26511 | CA |
N | 111NX0100X | Occupational Health | DC26511 | CA |
NPI | 1750446407 |
---|---|
Provider Name | Dr. Dennis M Wazac |
First Address | Folsom, CA 95630-3893 |
Second Address | Folsom, CA 95630-3893 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2006 |
Last Update Date | 27/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
ZZZ62244Z | BLUE SHIELD (01) | CA |