Provider Demographics
NPI:1194865477
Name:MARRIOTT, TED EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:EDWARD
Last Name:MARRIOTT
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 1:600 S LAKE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3955
Mailing Address - Country:US
Mailing Address - Phone:626-808-1515
Mailing Address - Fax:626-768-2158
Practice Address - Street 1:600 S LAKE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-3955
Practice Address - Country:US
Practice Address - Phone:626-808-1515
Practice Address - Fax:626-768-2158
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 21747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU32753Medicare UPIN
CADC0217470Medicare ID - Type Unspecified