Provider Demographics
NPI:1114093366
Name:WISE, ERIC RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:RICHARD
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 VALLEY RD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-4163
Mailing Address - Country:US
Mailing Address - Phone:619-564-4347
Mailing Address - Fax:
Practice Address - Street 1:1530 JAMACHA RD
Practice Address - Street 2:SUITE B1
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-3700
Practice Address - Country:US
Practice Address - Phone:619-444-3477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-30241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor