Provider Demographics
NPI:1144597006
Name:WIESENFARTH SIMONE, MARY ELLEN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:WIESENFARTH SIMONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:SIMONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:275 W SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1516
Mailing Address - Country:US
Mailing Address - Phone:626-967-3553
Mailing Address - Fax:626-967-1523
Practice Address - Street 1:275 W SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1516
Practice Address - Country:US
Practice Address - Phone:626-967-3553
Practice Address - Fax:626-967-1523
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22891111N00000X, 111NX0100X, 111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No111N00000XChiropractic ProvidersChiropractor
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC22891OtherLICENSE