Provider Demographics
NPI:1275696619
Name:TIMOTHY R TWOMBLY DC & KENNETH D ERICKSON DC A CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:TIMOTHY R TWOMBLY DC & KENNETH D ERICKSON DC A CHIROPRACTIC CORP
Other - Org Name:IRVINE SPINE AND SPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-857-1888
Mailing Address - Street 1:15520 ROCKFIELD BLVD
Mailing Address - Street 2:A220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2717
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:1110 ROOSEVELT
Practice Address - Street 2:SUITE# 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-3686
Practice Address - Country:US
Practice Address - Phone:949-857-1888
Practice Address - Fax:949-857-4536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ50052ZOtherBLUE SHIELD
CAW13236Medicare PIN
CA6207360001Medicare NSC