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General NPI Number Information
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NPI Number | 1235676800
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Entity Type | Individual
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Provider Name | JOHN WIESE ATC
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Gender | Male
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 01/20/2017
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Provider Practice Location Address
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Address Line | 13800 BIOLA AVE
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City | LA MIRADA
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State | CA
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Zip | 90639-0002
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Country | US
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Telephone | 562-944-0351
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Fax | 562-906-4558
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Provider Business Mailing Address
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Address Line | 5499 TRAIL ST
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City | NORCO
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State | CA
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Zip | 92860-2477
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Country | US
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Telephone | 951-738-1614
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Fax | 562-906-4558
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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