Provider Demographics
NPI:1598416216
Name:ANTOVICH, IAN (DC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:ANTOVICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8890 ELK GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1832
Mailing Address - Country:US
Mailing Address - Phone:916-684-4100
Mailing Address - Fax:
Practice Address - Street 1:8890 ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1832
Practice Address - Country:US
Practice Address - Phone:916-684-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor