Provider Demographics
NPI:1841415007
Name:ETTINGER, MASON STEWART (DC)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:STEWART
Last Name:ETTINGER
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 1:30290 RANCHO VIEJO RD
Mailing Address - Street 2:STE. 205
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1577
Mailing Address - Country:US
Mailing Address - Phone:714-345-0550
Mailing Address - Fax:
Practice Address - Street 1:30290 RANCHO VIEJO RD
Practice Address - Street 2:STE. 205
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1577
Practice Address - Country:US
Practice Address - Phone:714-345-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27221111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC27221Medicare UPIN