Healthcare Provider Details

I. General information

NPI: 1659402261
Provider Name (Legal Business Name): KATHI WOLFRUM D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W 25TH ST
SAN PEDRO CA
90732-4301
US

IV. Provider business mailing address

1611 W 25TH ST
SAN PEDRO CA
90732-4301
US

V. Phone/Fax

Practice location:
  • Phone: 310-833-3795
  • Fax:
Mailing address:
  • Phone: 310-833-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC21566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: