Provider Demographics
NPI:1417033127
Name:AZEVEDO CHIROPRACTIC, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:AZEVEDO CHIROPRACTIC, A PROFESSIONAL CORPORATION
Other - Org Name:CORE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT /CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:J
Authorized Official - Last Name:AZEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-927-1055
Mailing Address - Street 1:4070 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:CA
Mailing Address - Zip Code:93428-3023
Mailing Address - Country:US
Mailing Address - Phone:805-927-1055
Mailing Address - Fax:805-927-1701
Practice Address - Street 1:4070 WEST ST
Practice Address - Street 2:
Practice Address - City:CAMBRIA
Practice Address - State:CA
Practice Address - Zip Code:93428-3023
Practice Address - Country:US
Practice Address - Phone:805-927-1055
Practice Address - Fax:805-927-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27895111N00000X
CAAC12352171100000X
CAPT29969225100000X
CAPT35580225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABD107Medicare PIN