Provider Demographics
NPI:1083647051
Name:ACEBO, ANDRE MARCEL
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:MARCEL
Last Name:ACEBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:325 POSADA LN
Practice Address - Street 2:SUITE A-C
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4003
Practice Address - Country:US
Practice Address - Phone:805-542-6700
Practice Address - Fax:805-542-6791
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 20074111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1508AOtherCHCCC, TEMPLETON MEDICARE GROUP #
CAFHC70936FOtherTEMPLETON M/CAL #
CAW1508OtherMEDICARE GROUP NUMBER
CAW1508AOtherCHCCC, TEMPLETON MEDICARE GROUP #
CAFHC70936FOtherTEMPLETON M/CAL #
CAW1508AOtherCHCCC, TEMPLETON MEDICARE GROUP #
CAFHC03884FMedicaid
CA551978Medicare Oscar/Certification