Provider Demographics
NPI:1821086612
Name:CLOSE, MICHAEL L (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:CLOSE
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 1:1042 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6103
Mailing Address - Country:US
Mailing Address - Phone:323-244-8926
Mailing Address - Fax:323-656-4151
Practice Address - Street 1:1042 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6103
Practice Address - Country:US
Practice Address - Phone:323-656-4194
Practice Address - Fax:323-656-4151
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
7530163OtherAETNA
DC0266160OtherBLUE SHIELD
CADC26616Medicare ID - Type Unspecified
7530163OtherAETNA