Provider Demographics
NPI:1225119142
Name:DEWALD CHIROPRACTIC INC
Entity Type:Organization
Organization Name:DEWALD CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:661-266-3500
Mailing Address - Street 1:1037 W AVENUE N STE 101
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-2002
Mailing Address - Country:US
Mailing Address - Phone:661-266-3500
Mailing Address - Fax:661-266-3591
Practice Address - Street 1:1037 W AVENUE N
Practice Address - Street 2:101
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-2002
Practice Address - Country:US
Practice Address - Phone:661-266-3500
Practice Address - Fax:661-266-3591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21669111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ48855ZOtherBLUE SHIELD
CADC21669Medicare ID - Type Unspecified
CAZZZ48855ZOtherBLUE SHIELD