Provider Demographics
NPI:1679768139
Name:UNTALAN, WILFREDO JR (DC)
Entity type:Individual
Prefix:DR
First Name:WILFREDO
Middle Name:
Last Name:UNTALAN
Suffix:JR
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 1:5467 N. CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-5506
Mailing Address - Country:US
Mailing Address - Phone:562-799-7900
Mailing Address - Fax:
Practice Address - Street 1:5467 N. CHERRY AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-5506
Practice Address - Country:US
Practice Address - Phone:562-799-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28547111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU96623Medicare UPIN