Provider Demographics
NPI:1477576379
Name:WENNERHOLM, ERIC (DC, MS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:WENNERHOLM
Suffix:
Gender:M
Credentials:DC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1304
Mailing Address - Country:US
Mailing Address - Phone:707-442-0881
Mailing Address - Fax:707-442-1084
Practice Address - Street 1:1459 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1304
Practice Address - Country:US
Practice Address - Phone:707-442-0881
Practice Address - Fax:707-442-1084
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 19326111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT280530Medicare UPIN
CADC0193269Medicare ID - Type Unspecified