Provider Demographics
NPI:1386849297
Name:AGNELLI CHIROPRACTIC INC
Entity Type:Organization
Organization Name:AGNELLI CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AGNELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-669-0399
Mailing Address - Street 1:1254 IRVINE BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3509
Mailing Address - Country:US
Mailing Address - Phone:714-669-0399
Mailing Address - Fax:
Practice Address - Street 1:1254 IRVINE BLVD
Practice Address - Street 2:STE 150
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3509
Practice Address - Country:US
Practice Address - Phone:714-669-0399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30882111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN