Provider Demographics
NPI:1407965353
Name:KORTHUIS, EDWARD LEONARD (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEONARD
Last Name:KORTHUIS
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 1:12571 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5847
Mailing Address - Country:US
Mailing Address - Phone:760-241-2000
Mailing Address - Fax:760-241-2100
Practice Address - Street 1:12571 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5847
Practice Address - Country:US
Practice Address - Phone:760-241-2000
Practice Address - Fax:760-241-2100
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0195050Medicare ID - Type Unspecified
CAU13474Medicare UPIN