Provider Demographics
NPI:1962579672
Name:WOLLUM, DEBORAH W (DC)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:W
Last Name:WOLLUM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 ALAMO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2187
Mailing Address - Country:US
Mailing Address - Phone:805-520-2780
Mailing Address - Fax:805-306-1571
Practice Address - Street 1:3655 ALAMO ST STE 201
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2187
Practice Address - Country:US
Practice Address - Phone:805-520-2780
Practice Address - Fax:805-306-1571
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20444111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC20444Medicare ID - Type Unspecified
CADC020444Medicare UPIN