Provider Demographics
NPI:1619091832
Name:GOTTLIEB, TINA MARIE (DC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27393 YNEZ RD
Mailing Address - Street 2:SUITE 162
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5604
Mailing Address - Country:US
Mailing Address - Phone:951-699-5161
Mailing Address - Fax:951-699-5175
Practice Address - Street 1:27393 YNEZ RD
Practice Address - Street 2:SUITE 162
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5604
Practice Address - Country:US
Practice Address - Phone:951-699-5161
Practice Address - Fax:951-699-5175
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU64880Medicare UPIN
CADC0243860Medicare ID - Type Unspecified