Provider Demographics
NPI:1275961302
Name:DEFAZIO CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:DEFAZIO CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-659-1775
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-7176
Mailing Address - Country:US
Mailing Address - Phone:858-509-7999
Mailing Address - Fax:858-509-3993
Practice Address - Street 1:206 S ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2811
Practice Address - Country:US
Practice Address - Phone:310-659-1775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19752111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC19752Medicare PIN