Provider Demographics
NPI:1487684205
Name:RANDY R. WIRTZ CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:RANDY R. WIRTZ CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-584-2404
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0308
Mailing Address - Country:US
Mailing Address - Phone:805-584-2404
Mailing Address - Fax:
Practice Address - Street 1:2045 ROYAL AVE.
Practice Address - Street 2:STE.#102
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065
Practice Address - Country:US
Practice Address - Phone:805-584-2404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26326111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC26326Medicare PIN