Provider Demographics
NPI:1598980344
Name:ENNEN, JOHN RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:ENNEN
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 1:13420 NEWPORT AVE
Mailing Address - Street 2:STE.K
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3745
Mailing Address - Country:US
Mailing Address - Phone:714-669-3105
Mailing Address - Fax:714-669-3108
Practice Address - Street 1:13420 NEWPORT AVE
Practice Address - Street 2:STE.K
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3745
Practice Address - Country:US
Practice Address - Phone:714-669-3105
Practice Address - Fax:714-669-3108
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 25433111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition