Provider Demographics
NPI:1356860498
Name:WENGRYN, MARA (DC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:WENGRYN
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 1:23686 324TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50065-4230
Mailing Address - Country:US
Mailing Address - Phone:641-442-5028
Mailing Address - Fax:
Practice Address - Street 1:303 SW LORRAINE ST STE C
Practice Address - Street 2:
Practice Address - City:LEON
Practice Address - State:IA
Practice Address - Zip Code:50144-1101
Practice Address - Country:US
Practice Address - Phone:641-442-5028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1950111N00000X
IA087424111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor