Provider Demographics
NPI:1750505269
Name:WUNDERLICH CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:WUNDERLICH CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WUNDERLICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-540-9888
Mailing Address - Street 1:1402 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-9763
Mailing Address - Country:US
Mailing Address - Phone:239-540-9888
Mailing Address - Fax:239-540-9889
Practice Address - Street 1:1402 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9763
Practice Address - Country:US
Practice Address - Phone:239-540-9888
Practice Address - Fax:239-540-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55461OtherBCBS ID#
FLAB985OtherMEDICARE DOC PROV #
FLCH7090OtherSTATE LICENSE
FLU63554Medicare UPIN