Provider Demographics
NPI:1033137021
Name:PRIESTLEY, KEVIN F (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:F
Last Name:PRIESTLEY
Suffix:
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 1:3 CORPORATE PLAZA DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7905
Mailing Address - Country:US
Mailing Address - Phone:949-640-7030
Mailing Address - Fax:949-640-0356
Practice Address - Street 1:3 CORPORATE PLAZA DR
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7905
Practice Address - Country:US
Practice Address - Phone:949-640-7030
Practice Address - Fax:949-640-0356
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13648111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 13648Medicare ID - Type Unspecified
CA33-0035260Medicare UPIN