Provider Demographics
NPI:1033243696
Name:KEVIN F PRIESTLEY CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:KEVIN F PRIESTLEY CHIROPRACTIC CORPORATION
Other - Org Name:PRIESTLEY CHIROPRACTIC GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:PRIESTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-640-7030
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:92660-7932
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:92660-7932
Practice Address - Country:US
Practice Address - Phone:949-640-7030
Practice Address - Fax:949-640-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13648111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA350004156OtherRAILROAD MEDICARE
CA=========OtherTAX ID
CADC13648Medicare ID - Type UnspecifiedLICENSE