Provider Demographics
NPI:1346235546
Name:POULOS, STEVEN (D C)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:POULOS
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80356
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-0356
Mailing Address - Country:US
Mailing Address - Phone:949-707-4556
Mailing Address - Fax:949-859-6606
Practice Address - Street 1:26072 MERIT CIR
Practice Address - Street 2:SUITE 119
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7015
Practice Address - Country:US
Practice Address - Phone:949-707-4556
Practice Address - Fax:949-859-6606
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU63140Medicare UPIN
CADC24562Medicare ID - Type UnspecifiedPROVIDER NUMBER