Provider Demographics
NPI:1497731772
Name:MATHIS, DIANE EVA (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:EVA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 OVERLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4128
Mailing Address - Country:US
Mailing Address - Phone:310-287-1108
Mailing Address - Fax:310-287-1123
Practice Address - Street 1:4315 OVERLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4128
Practice Address - Country:US
Practice Address - Phone:310-287-1108
Practice Address - Fax:310-287-1123
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 19907111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition