Provider Demographics
NPI:1346445475
Name:VANOTTEN, CRAIG ALAN (DC)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ALAN
Last Name:VANOTTEN
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:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:SOULSBYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95372-0087
Mailing Address - Country:US
Mailing Address - Phone:209-694-0223
Mailing Address - Fax:510-249-9659
Practice Address - Street 1:3909 STEVENSON BLVD STE D
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2301
Practice Address - Country:US
Practice Address - Phone:510-249-9037
Practice Address - Fax:510-249-9659
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV17620Medicare UPIN
CADC0186780Medicare ID - Type Unspecified