Provider Demographics
NPI:1053500892
Name:GOLAN NISSIM PROFESSIONAL CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:GOLAN NISSIM PROFESSIONAL CHIROPRACTIC CORPORATION
Other - Org Name:PERFORMANCE CARE CHIROPRACITC & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GOLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC, ART
Authorized Official - Phone:818-766-4307
Mailing Address - Street 1:10738 RIVERSIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2372
Mailing Address - Country:US
Mailing Address - Phone:818-766-4307
Mailing Address - Fax:818-766-4309
Practice Address - Street 1:10738 RIVERSIDE DR STE A
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2372
Practice Address - Country:US
Practice Address - Phone:818-766-4307
Practice Address - Fax:818-766-4309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25362111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18054Medicare UPIN