Provider Demographics
NPI:1710901657
Name:ONTIVEROS, THOMAS ANTHONY (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ANTHONY
Last Name:ONTIVEROS
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 1:1515 W 190TH ST
Mailing Address - Street 2:STE 510
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4933
Mailing Address - Country:US
Mailing Address - Phone:714-994-1131
Mailing Address - Fax:714-994-4415
Practice Address - Street 1:1515 W 190TH ST
Practice Address - Street 2:STE 510
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4933
Practice Address - Country:US
Practice Address - Phone:714-994-1131
Practice Address - Fax:714-994-4415
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor