Healthcare Provider Details

I. General information

NPI: 1326685611
Provider Name (Legal Business Name): SEAN NIKOLAS WUNDERLE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 PEARL RD UNIT B
BRUNSWICK OH
44212-6477
US

IV. Provider business mailing address

1930 PEARL RD UNIT B
BRUNSWICK OH
44212-6477
US

V. Phone/Fax

Practice location:
  • Phone: 330-558-1119
  • Fax:
Mailing address:
  • Phone: 330-558-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberDC-04896
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: