Provider Demographics
NPI:1497833370
Name:CHANG, OLIVIA (DC)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2148 AVENIDA DE LA PLAYA STE C
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3216
Mailing Address - Country:US
Mailing Address - Phone:619-807-1002
Mailing Address - Fax:
Practice Address - Street 1:2148 AVENIDA DE LA PLAYA STE C
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-3216
Practice Address - Country:US
Practice Address - Phone:619-807-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21267Medicare ID - Type UnspecifiedCHIROPRACTOR