Provider Demographics
NPI:1184819211
Name:BLUMHARDT FAMILY CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:BLUMHARDT FAMILY CHIROPRACTIC, PC
Other - Org Name:FOUNTAIN OF LIFE CHIROSTUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUMHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-665-9355
Mailing Address - Street 1:14081 YORBA ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2010
Mailing Address - Country:US
Mailing Address - Phone:714-665-9355
Mailing Address - Fax:866-265-6179
Practice Address - Street 1:14081 YORBA ST
Practice Address - Street 2:SUITE 106
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2010
Practice Address - Country:US
Practice Address - Phone:714-665-9355
Practice Address - Fax:866-265-6179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30606111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty