Provider Demographics
NPI:1164453460
Name:CHRISTOPHERSON, DIANE (DC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:CHRISTOPHERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:CHRISTOPHERSON-REEDD.C
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1278 GLENNEYRE ST STE 233
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3103
Mailing Address - Country:US
Mailing Address - Phone:949-497-3212
Mailing Address - Fax:949-497-1564
Practice Address - Street 1:1502 N. COAST HIGHWAY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-3103
Practice Address - Country:US
Practice Address - Phone:949-497-3212
Practice Address - Fax:949-497-1564
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18358111NX0800X
CA18358111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0183580OtherBLUE SHIELD
CADC18358Medicare PIN
CA10505Medicare UPIN