Provider Demographics
NPI:1326063165
Name:FRAGOSO, JOHN (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2062 TALBERT DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7679
Mailing Address - Country:US
Mailing Address - Phone:530-891-9010
Mailing Address - Fax:530-893-0404
Practice Address - Street 1:2062 TALBERT DR
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-7679
Practice Address - Country:US
Practice Address - Phone:530-891-9010
Practice Address - Fax:530-893-0404
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29342111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0293420Medicare ID - Type Unspecified