Provider Demographics
NPI:1326038134
Name:LISA DE LA TORRES MAIN STREET CHIROPRACTIC INC
Entity Type:Organization
Organization Name:LISA DE LA TORRES MAIN STREET CHIROPRACTIC INC
Other - Org Name:MAIN STREET CHIROPRACTIC, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA TORRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-395-4333
Mailing Address - Street 1:291 E MAIN ST
Mailing Address - Street 2:B1
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-6137
Mailing Address - Country:US
Mailing Address - Phone:408-395-4333
Mailing Address - Fax:408-395-7692
Practice Address - Street 1:291 E MAIN ST
Practice Address - Street 2:B1
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-6137
Practice Address - Country:US
Practice Address - Phone:408-395-4333
Practice Address - Fax:408-395-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02375ZMedicare PIN