Provider Demographics
NPI:1558570192
Name:MICHAEL D BERRY DC, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL D BERRY DC, A PROFESSIONAL CORPORATION
Other - Org Name:KATELLA CHIROPRACTIC FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-639-4640
Mailing Address - Street 1:1500 E KATELLA AVE
Mailing Address - Street 2:SUITE O
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-6302
Mailing Address - Country:US
Mailing Address - Phone:714-639-4640
Mailing Address - Fax:714-639-5628
Practice Address - Street 1:1500 E KATELLA AVE
Practice Address - Street 2:SUITE O
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-6302
Practice Address - Country:US
Practice Address - Phone:714-639-4640
Practice Address - Fax:714-639-5628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC11854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0118540AOtherBLUE SHIELD IDENTIFIER
CAWDC8346Medicare PIN