Provider Demographics
NPI:1003087156
Name:REZA, EDWARD JR (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:REZA
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:122 S GLASSELL ST
Mailing Address - Street 2:#17
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1429
Mailing Address - Country:US
Mailing Address - Phone:949-398-6353
Mailing Address - Fax:949-398-6354
Practice Address - Street 1:4341 BIRCH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1924
Practice Address - Country:US
Practice Address - Phone:949-398-6353
Practice Address - Fax:949-398-6354
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC28729111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28729OtherCHIROPRACTIC LICENSE