Provider Demographics
NPI:1679622138
Name:MADDALON, LORIS A (DC)
Entity Type:Individual
Prefix:
First Name:LORIS
Middle Name:A
Last Name:MADDALON
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 1:400 W LAMBERT RD
Mailing Address - Street 2:SUITE A2
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3936
Mailing Address - Country:US
Mailing Address - Phone:714-671-0892
Mailing Address - Fax:714-671-0968
Practice Address - Street 1:400 W LAMBERT RD
Practice Address - Street 2:SUITE A2
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3936
Practice Address - Country:US
Practice Address - Phone:714-671-0892
Practice Address - Fax:714-671-0968
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16710111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC16710Medicare PIN