Provider Demographics
NPI:1477898781
Name:SO CAL CHIROPRACTIC
Entity Type:Organization
Organization Name:SO CAL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ACE
Authorized Official - Middle Name:S
Authorized Official - Last Name:THAYER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-548-7767
Mailing Address - Street 1:129 W WILSON ST
Mailing Address - Street 2:STE 104
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1586
Mailing Address - Country:US
Mailing Address - Phone:949-548-7767
Mailing Address - Fax:949-548-5692
Practice Address - Street 1:129 W WILSON ST
Practice Address - Street 2:STE 104
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1586
Practice Address - Country:US
Practice Address - Phone:949-548-7767
Practice Address - Fax:949-548-5692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU63220Medicare UPIN