Healthcare Provider Details

I. General information

NPI: 1063503118
Provider Name (Legal Business Name): KATHRYN NIELSEN-WINES D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 BEAUMONT AVE
BEAUMONT CA
92223-1833
US

IV. Provider business mailing address

1074 BEAUMONT AVE
BEAUMONT CA
92223-1833
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-6456
  • Fax: 951-845-7485
Mailing address:
  • Phone: 951-845-6456
  • Fax: 951-845-7485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number16014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: