Provider Demographics
NPI:1164794699
Name:WILFONG, SAMANTHA (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:WILFONG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 PARK AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-1243
Mailing Address - Country:US
Mailing Address - Phone:814-337-0070
Mailing Address - Fax:814-337-0300
Practice Address - Street 1:390 PARK AVE
Practice Address - Street 2:STE 105
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-1243
Practice Address - Country:US
Practice Address - Phone:814-337-0070
Practice Address - Fax:814-337-0300
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor