Provider Demographics
NPI:1790930139
Name:BOCCHINO, ANTHONY L
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:L
Last Name:BOCCHINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17897 MACARTHUR BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-0532
Mailing Address - Country:US
Mailing Address - Phone:949-251-9355
Mailing Address - Fax:949-251-0329
Practice Address - Street 1:17897 MACARTHUR BLVD
Practice Address - Street 2:STE 101
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-0532
Practice Address - Country:US
Practice Address - Phone:949-251-9355
Practice Address - Fax:949-251-0329
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18336111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC18336Medicare UPIN