Provider Demographics
NPI:1619041852
Name:THAYER, ACE S (DC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:ACE
Middle Name:S
Last Name:THAYER
Suffix:
Gender:M
Credentials:DC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W WILSON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1586
Mailing Address - Country:US
Mailing Address - Phone:949-548-7767
Mailing Address - Fax:949-548-5692
Practice Address - Street 1:129 W WILSON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1586
Practice Address - Country:US
Practice Address - Phone:949-548-7767
Practice Address - Fax:949-548-5692
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC24008Medicare ID - Type Unspecified
CAU63220Medicare UPIN