Provider Demographics
NPI:1275059719
Name:DAVID S MANTECA FAMILY CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:DAVID S MANTECA FAMILY CHIROPRACTIC CORPORATION
Other - Org Name:DAVID S MANTECA FAMILY CHIROPRACTIC CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:209-239-2121
Mailing Address - Street 1:965 E YOSEMITE AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5943
Mailing Address - Country:US
Mailing Address - Phone:209-239-2121
Mailing Address - Fax:209-239-3144
Practice Address - Street 1:965 E YOSEMITE AVE STE 9
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5943
Practice Address - Country:US
Practice Address - Phone:209-239-2121
Practice Address - Fax:209-239-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23641305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043217284Medicaid