Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC24241 | CA |
NPI | 1700870706 |
---|---|
Provider Name | Dr. Mark Wardenburg |
First Address | Irvine, CA 92612-2729 |
Second Address | Irvine, CA 92612-2729 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V60238 | (02) | CA |