Healthcare Provider Details

I. General information

NPI: 1518037704
Provider Name (Legal Business Name): WAYNE L. WUNDRAM D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1414 W MAIN ST
VISALIA CA
93291-5823
US

IV. Provider business mailing address

1414 W MAIN ST
VISALIA CA
93291-5823
US

V. Phone/Fax

Practice location:
  • Phone: 559-734-3298
  • Fax: 559-734-3297
Mailing address:
  • Phone: 559-734-3298
  • Fax: 559-734-3297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC11832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: