Provider Demographics
NPI:1508900838
Name:SPORTS AND FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:SPORTS AND FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BRADFORD
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-956-2225
Mailing Address - Street 1:1842 W LINCOLN AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5426
Mailing Address - Country:US
Mailing Address - Phone:714-956-2225
Mailing Address - Fax:714-956-5350
Practice Address - Street 1:1842 W LINCOLN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5426
Practice Address - Country:US
Practice Address - Phone:714-956-2225
Practice Address - Fax:714-956-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0230590Medicaid
CADC0230590OtherSERVICE LINE PIN
CADC023059OtherSTATE LICENSE