Healthcare Provider Details

I. General information

NPI: 1588877526
Provider Name (Legal Business Name): MICHELE LISA WIMMER CSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 PLAYGROUND DR.
CRESTLINE CA
92325
US

IV. Provider business mailing address

P.O. BOX 701
TWIN PEAKS CA
92391-0701
US

V. Phone/Fax

Practice location:
  • Phone: 909-338-9969
  • Fax: 909-338-2341
Mailing address:
  • Phone: 909-338-9969
  • Fax: 909-338-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: