Provider Demographics
NPI:1225257306
Name:BEACH CHIROPRACTIC SPORTS CENTER INC
Entity Type:Organization
Organization Name:BEACH CHIROPRACTIC SPORTS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALEK OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-965-9577
Mailing Address - Street 1:19900 BEACH BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3762
Mailing Address - Country:US
Mailing Address - Phone:714-965-9577
Mailing Address - Fax:714-965-9580
Practice Address - Street 1:19900 BEACH BLVD STE A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-3762
Practice Address - Country:US
Practice Address - Phone:714-965-9577
Practice Address - Fax:714-965-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT17977Medicare UPIN
CAU37107Medicare UPIN
CAG07441Medicare UPIN