Provider Demographics
NPI:1710216643
Name:VENDETTA, MARY VENDETTA (DC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:VENDETTA
Last Name:VENDETTA
Suffix:
Gender:F
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:P.O. BOX 4298
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92628-4298
Mailing Address - Country:US
Mailing Address - Phone:949-548-5800
Mailing Address - Fax:949-548-5803
Practice Address - Street 1:1905 FULLERTON AVE, #A
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2277
Practice Address - Country:US
Practice Address - Phone:949-548-5800
Practice Address - Fax:949-548-5803
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22881111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor