Provider Demographics
NPI:1598392144
Name:MAEDO, WESLEY MINORU
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:MINORU
Last Name:MAEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 ORANGETHORPE AVE STE 3B
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4660
Mailing Address - Country:US
Mailing Address - Phone:714-522-1111
Mailing Address - Fax:714-522-1114
Practice Address - Street 1:7212 ORANGETHORPE AVE STE 3B
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4660
Practice Address - Country:US
Practice Address - Phone:714-522-1111
Practice Address - Fax:714-522-1114
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty