Provider Demographics
NPI:1598923716
Name:NAZARETH CLINIC CORP
Entity Type:Organization
Organization Name:NAZARETH CLINIC CORP
Other - Org Name:NAZARETH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:213-389-5865
Mailing Address - Street 1:2140 W OLYMPIC BLVD STE 321
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2279
Mailing Address - Country:US
Mailing Address - Phone:213-389-5865
Mailing Address - Fax:
Practice Address - Street 1:2140 W OLYMPIC BLVD STE 321
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2279
Practice Address - Country:US
Practice Address - Phone:213-389-5865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25845111N00000X
CADC 25845111NS0005X
CAAC 6463171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 25845OtherCALIFORNIA BOARD OF CHIROPRACTIC EXAMINERS
CAAC 6463OtherCALIFORNIA ACUPUNCTURE BOARD