Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC11832 | CA |
NPI | 1518037704 |
---|---|
Provider Name | Dr. Wayne L. Wundram |
First Address | Visalia, CA 93291-5823 |
Second Address | Visalia, CA 93291-5823 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
TD 4508 | (02) | CA |