Provider Demographics
NPI:1417253410
Name:ANTHONY FEDORYK DC & EDWARD REZA JR DC PROFESSIONAL CHIROPRACTIC CORPO
Entity Type:Organization
Organization Name:ANTHONY FEDORYK DC & EDWARD REZA JR DC PROFESSIONAL CHIROPRACTIC CORPO
Other - Org Name:ET CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDORYK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-398-6353
Mailing Address - Street 1:4341 BIRCH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1924
Mailing Address - Country:US
Mailing Address - Phone:949-398-6353
Mailing Address - Fax:949-398-6354
Practice Address - Street 1:4341 BIRCH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1924
Practice Address - Country:US
Practice Address - Phone:949-398-6353
Practice Address - Fax:949-398-6354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28888111N00000X
CADC28729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty