Provider Demographics
NPI:1235213554
Name:UDEZE, ALOYSIUS IFEANYI (DC, BSC, IDE, DABDA)
Entity Type:Individual
Prefix:DR
First Name:ALOYSIUS
Middle Name:IFEANYI
Last Name:UDEZE
Suffix:
Gender:M
Credentials:DC, BSC, IDE, DABDA
Other - Prefix:DR
Other - First Name:AL
Other - Middle Name:I
Other - Last Name:UDEZE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:11012 CHANERA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2427
Mailing Address - Country:US
Mailing Address - Phone:310-390-9293
Mailing Address - Fax:323-820-1718
Practice Address - Street 1:12613 VENICE BLVD
Practice Address - Street 2:13523 LEMOLI AVENUE HAWTHORNE, CA 90250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3703
Practice Address - Country:US
Practice Address - Phone:310-390-9293
Practice Address - Fax:323-820-1718
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24645111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC24645B CAOtherMEDICARE W18417 CA
CAZZZ64099ZOtherZZZ64099Z CA
CADC0246450OtherDOCTOR'S BLUE SHIELD PIN#
WDC24645B CAMedicare PIN
CAZZZ64099ZOtherZZZ64099Z CA
CADC24645Medicare PIN