Provider Demographics
NPI:1952727224
Name:WISEMAN, CHAMPION
Entity Type:Individual
Prefix:
First Name:CHAMPION
Middle Name:
Last Name:WISEMAN
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 1:1905 E 17TH ST
Mailing Address - Street 2:309
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8628
Mailing Address - Country:US
Mailing Address - Phone:714-543-0425
Mailing Address - Fax:714-543-2062
Practice Address - Street 1:1905 E 17TH ST
Practice Address - Street 2:309
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8628
Practice Address - Country:US
Practice Address - Phone:714-543-0425
Practice Address - Fax:714-543-2062
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor