Healthcare Provider Details

I. General information

NPI: 1730255233
Provider Name (Legal Business Name): WAYNE DOUGLASS MATHIS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 W. MAGNOLIA BLVD.
BURBANK CA
91505
US

IV. Provider business mailing address

10832 CROCKETT ST.
SUN VALLEY CA
91352
US

V. Phone/Fax

Practice location:
  • Phone: 818-845-5895
  • Fax: 818-954-8634
Mailing address:
  • Phone: 818-768-4502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License NumberDC15307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: