Provider Demographics
NPI:1639250103
Name:STORM, ERIC JON (DC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JON
Last Name:STORM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16727 BEAR VALLEY RD # 260
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1406
Mailing Address - Country:US
Mailing Address - Phone:760-949-3969
Mailing Address - Fax:760-949-0697
Practice Address - Street 1:16727 BEAR VALLEY RD # 260
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1406
Practice Address - Country:US
Practice Address - Phone:760-949-3969
Practice Address - Fax:760-949-0697
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16072111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T06009Medicare UPIN
DC0160720Medicare ID - Type Unspecified