Provider Demographics
NPI:1447416631
Name:MCCLAIN SPORTS & WELLNESS INC A PROFESSIONAL CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:MCCLAIN SPORTS & WELLNESS INC A PROFESSIONAL CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESITDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIONNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:323-653-1014
Mailing Address - Street 1:6360 WILSHIRE BLVD STE 410
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5606
Mailing Address - Country:US
Mailing Address - Phone:323-653-1014
Mailing Address - Fax:
Practice Address - Street 1:6360 WILSHIRE BLVD STE 410
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5606
Practice Address - Country:US
Practice Address - Phone:323-653-1014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU69160Medicare UPIN