Provider Demographics
NPI:1629008370
Name:AMBRIDGE CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:AMBRIDGE CHIROPRACTIC CORP
Other - Org Name:SANTA ROSA CHIROPRACTIC NEUROLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:AMBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-575-9009
Mailing Address - Street 1:3540 MENDOCINO AVE
Mailing Address - Street 2:#300
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2276
Mailing Address - Country:US
Mailing Address - Phone:707-575-9009
Mailing Address - Fax:707-575-4267
Practice Address - Street 1:990 SONOMA AVE STE 18
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4813
Practice Address - Country:US
Practice Address - Phone:707-575-9009
Practice Address - Fax:707-575-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19037111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04893ZOtherBLUE SHIELD PROVIDER