Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC 19326 | CA |
NPI | 1477576379 |
---|---|
Provider Name | Dr. Eric Wennerholm |
First Address | Eureka, CA 95501-3230 |
Second Address | Eureka, CA 95501-3230 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T280530 | (02) | CA |