Provider Demographics
NPI:1265445837
Name:VAN DEUSEN, ELISHA BLACKMAR IV (DC)
Entity Type:Individual
Prefix:DR
First Name:ELISHA
Middle Name:BLACKMAR
Last Name:VAN DEUSEN
Suffix:IV
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:17220 NEWHOPE ST
Mailing Address - Street 2:SUITE 123
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4272
Mailing Address - Country:US
Mailing Address - Phone:714-556-6966
Mailing Address - Fax:714-556-6967
Practice Address - Street 1:17220 NEWHOPE ST
Practice Address - Street 2:SUITE 123
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4272
Practice Address - Country:US
Practice Address - Phone:714-556-6966
Practice Address - Fax:714-556-6967
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC28866111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC28866AMedicare ID - Type Unspecified