Provider Demographics
NPI:1104859552
Name:BANTIQUE, CARMELO DICHOSA JR (DC)
Entity Type:Individual
Prefix:DR
First Name:CARMELO
Middle Name:DICHOSA
Last Name:BANTIQUE
Suffix:JR
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 1:3301 WATT AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-3621
Mailing Address - Country:US
Mailing Address - Phone:916-483-3423
Mailing Address - Fax:916-483-8555
Practice Address - Street 1:3301 WATT AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-3621
Practice Address - Country:US
Practice Address - Phone:916-483-3423
Practice Address - Fax:916-483-8555
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29892111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0298920Medicare UPIN