Provider Demographics
NPI:1154495836
Name:DAGOSTINO, CHRIS MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:MICHAEL
Last Name:DAGOSTINO
Suffix:
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 1:41750 RANCHO LAS PALMAS DR
Mailing Address - Street 2:SUITE E2
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5511
Mailing Address - Country:US
Mailing Address - Phone:760-773-2600
Mailing Address - Fax:760-773-2608
Practice Address - Street 1:41750 RANCHO LAS PALMAS DR
Practice Address - Street 2:SUITE E2
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-5511
Practice Address - Country:US
Practice Address - Phone:760-773-2600
Practice Address - Fax:760-773-2608
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15171111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEV421ZMedicare PIN