Healthcare Provider Details

I. General information

NPI: 1144597006
Provider Name (Legal Business Name): MRS. MARY ELLEN WIESENFARTH SIMONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ELLEN SIMONE D.C.

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W SAN BERNARDINO RD
COVINA CA
91723-1516
US

IV. Provider business mailing address

275 W SAN BERNARDINO RD
COVINA CA
91723-1516
US

V. Phone/Fax

Practice location:
  • Phone: 626-967-3553
  • Fax: 626-967-1523
Mailing address:
  • Phone: 626-967-3553
  • Fax: 626-967-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC22891
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberDC22891
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberDC22891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: