Provider Demographics
NPI:1649201278
Name:RETTIG, ROBERT R (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:RETTIG
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 1:4330 BARRANCA PARKWAY
Mailing Address - Street 2:SUITE 150-B
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604
Mailing Address - Country:US
Mailing Address - Phone:949-559-7999
Mailing Address - Fax:949-559-5582
Practice Address - Street 1:4330 BARRANCA PKWY
Practice Address - Street 2:SUITE 150-B
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4755
Practice Address - Country:US
Practice Address - Phone:949-559-7999
Practice Address - Fax:949-559-5582
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC18018AOtherMEDICARE PTAN