Provider Demographics
NPI:1225457369
Name:GUNDLACH, JON
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:GUNDLACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17524 VON KARMAN AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6208
Mailing Address - Country:US
Mailing Address - Phone:949-722-7070
Mailing Address - Fax:
Practice Address - Street 1:17524 VON KARMAN AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6208
Practice Address - Country:US
Practice Address - Phone:949-722-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor