Provider Demographics
NPI:1629149281
Name:COCAIN CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:COCAIN CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:COCAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-644-5563
Mailing Address - Street 1:4247 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3705
Mailing Address - Country:US
Mailing Address - Phone:805-644-5563
Mailing Address - Fax:805-644-3430
Practice Address - Street 1:4247 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3705
Practice Address - Country:US
Practice Address - Phone:805-644-5563
Practice Address - Fax:805-644-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC9841111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0098410Medicaid
CAT19025Medicare UPIN
CAWDC1014Medicare PIN