Provider Demographics
NPI:1376783399
Name:ACOSTA CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:ACOSTA CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-354-6294
Mailing Address - Street 1:11498 PIERCE ST
Mailing Address - Street 2:STE #B
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3357
Mailing Address - Country:US
Mailing Address - Phone:951-354-6294
Mailing Address - Fax:951-354-6295
Practice Address - Street 1:11498 PIERCE ST
Practice Address - Street 2:STE #B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3357
Practice Address - Country:US
Practice Address - Phone:951-354-6294
Practice Address - Fax:951-354-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30073111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC30073OtherSTATE LICENSE