Healthcare Provider Details

I. General information

NPI: 1780440891
Provider Name (Legal Business Name): AMANDA LEIGH WAINFAN DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 MESA VERDE DR E STE 108
COSTA MESA CA
92626-5221
US

IV. Provider business mailing address

1525 MESA VERDE DR E STE 108
COSTA MESA CA
92626-5221
US

V. Phone/Fax

Practice location:
  • Phone: 714-502-4243
  • Fax: 866-622-9879
Mailing address:
  • Phone: 714-502-4243
  • Fax: 866-622-9879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC36915
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: