Healthcare Provider Details

I. General information

NPI: 1922559889
Provider Name (Legal Business Name): SAMANTHA WUNDER D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N RIDGEWOOD AVE STE 1300
EDGEWATER FL
32132-1617
US

IV. Provider business mailing address

315 N RIDGEWOOD AVE
EDGEWATER FL
32132-1617
US

V. Phone/Fax

Practice location:
  • Phone: 386-427-8403
  • Fax: 386-269-9541
Mailing address:
  • Phone: 386-427-8403
  • Fax: 386-269-9541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH11990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: