Provider Demographics
NPI: | 1861669335 |
---|---|
Name: | FAMILY CHIROPRACTIC CENTER |
Entity Type: | Organization |
Organization Name: | FAMILY CHIROPRACTIC CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DOUGLAS |
Authorized Official - Middle Name: | ROBERT |
Authorized Official - Last Name: | ROCHE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 858-578-0058 |
Mailing Address - Street 1: | 12285 SCRIPPS POWAY PKWY |
Mailing Address - Street 2: | SUITE 103 |
Mailing Address - City: | POWAY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92064-6149 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 858-578-0058 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 12285 SCRIPPS POWAY PKWY |
Practice Address - Street 2: | SUITE 103 |
Practice Address - City: | POWAY |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92064-6149 |
Practice Address - Country: | US |
Practice Address - Phone: | 858-578-0058 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-05-13 |
Last Update Date: | 2008-05-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 22140 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |