Provider Demographics
NPI:1568573392
Name:FANTASIA CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:FANTASIA CHIROPRACTIC CORPORATION
Other - Org Name:UNITED CHIROPRACTIC HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:HUGO
Authorized Official - Last Name:FANTASIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC FCTS
Authorized Official - Phone:909-984-2765
Mailing Address - Street 1:410 N LEMON ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-3732
Mailing Address - Country:US
Mailing Address - Phone:909-984-2765
Mailing Address - Fax:909-467-5594
Practice Address - Street 1:410 N LEMON ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-3732
Practice Address - Country:US
Practice Address - Phone:909-984-2765
Practice Address - Fax:909-467-5594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0154640111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T05774Medicare UPIN