Healthcare Provider Details

I. General information

NPI: 1457985459
Provider Name (Legal Business Name): MICHAEL JOHN WENSTRUP DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 S VAL VISTA DR STE 105
GILBERT AZ
85296-3131
US

IV. Provider business mailing address

3301 E ANGELA DR
PHOENIX AZ
85032-2097
US

V. Phone/Fax

Practice location:
  • Phone: 480-497-2900
  • Fax:
Mailing address:
  • Phone: 480-747-7486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8904
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: