Provider Demographics
NPI:1720598089
Name:PRUSS CHIROPRACTIC CORPROATION
Entity Type:Organization
Organization Name:PRUSS CHIROPRACTIC CORPROATION
Other - Org Name:BACK PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-703-1139
Mailing Address - Street 1:19141 SUMMERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6608
Mailing Address - Country:US
Mailing Address - Phone:248-703-1139
Mailing Address - Fax:
Practice Address - Street 1:532 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-1552
Practice Address - Country:US
Practice Address - Phone:562-439-0419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-01
Last Update Date:2017-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33922OtherCHIROPRACTIC LICENSE