Provider Demographics
NPI:1356481477
Name:TETZLAFF CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:TETZLAFF CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:TETZLAFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:209-538-0647
Mailing Address - Street 1:2450 E WHITMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2637
Mailing Address - Country:US
Mailing Address - Phone:209-538-0647
Mailing Address - Fax:209-538-8737
Practice Address - Street 1:2450 E WHITMORE AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2637
Practice Address - Country:US
Practice Address - Phone:209-538-0647
Practice Address - Fax:209-538-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
189770111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA189770OtherCHIROPRACTIC LICENSE
CA=========OtherTAX ID NUMBER
CADC0189770Medicare ID - Type Unspecified