Provider Demographics
NPI:1144245283
Name:MUMBAUER, ERIC PHILLIP (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:PHILLIP
Last Name:MUMBAUER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:MUMBAUER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:601 S BRAND BLVD
Mailing Address - Street 2:ST 103
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4040
Mailing Address - Country:US
Mailing Address - Phone:818-365-0653
Mailing Address - Fax:818-365-6533
Practice Address - Street 1:601 S BRAND BLVD
Practice Address - Street 2:ST 103
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4040
Practice Address - Country:US
Practice Address - Phone:818-365-0653
Practice Address - Fax:818-365-6533
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC11343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT04299Medicare UPIN
CAT0429000004704Medicare ID - Type UnspecifiedMEDICARE