Provider Demographics
NPI:1609922038
Name:TIM G. URSICH CHIROPRATIC, INC.
Entity Type:Organization
Organization Name:TIM G. URSICH CHIROPRATIC, INC.
Other - Org Name:MARINA SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:URSICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-832-2622
Mailing Address - Street 1:28633 S WESTERN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0827
Mailing Address - Country:US
Mailing Address - Phone:310-832-2622
Mailing Address - Fax:310-832-2621
Practice Address - Street 1:28633 S WESTERN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0827
Practice Address - Country:US
Practice Address - Phone:310-832-2622
Practice Address - Fax:310-832-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12564111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC12564Medicare ID - Type UnspecifiedMEDICARE ID#