Provider Demographics
NPI:1518037704
Name:WUNDRAM, WAYNE L (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
Last Name:WUNDRAM
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 1:1414 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5823
Mailing Address - Country:US
Mailing Address - Phone:559-734-3298
Mailing Address - Fax:559-734-3297
Practice Address - Street 1:1414 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5823
Practice Address - Country:US
Practice Address - Phone:559-734-3298
Practice Address - Fax:559-734-3297
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC11832111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATD 4508Medicare UPIN
CADC0118320Medicare ID - Type Unspecified