Provider Demographics
NPI:1417229303
Name:WYMORE, PATRICK JEROME (DC)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JEROME
Last Name:WYMORE
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 1:900 E WASHINGTON ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-7111
Mailing Address - Country:US
Mailing Address - Phone:909-824-2422
Mailing Address - Fax:909-824-8234
Practice Address - Street 1:900 E WASHINGTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-7111
Practice Address - Country:US
Practice Address - Phone:909-824-2422
Practice Address - Fax:909-824-8234
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 18700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor