Provider Demographics
NPI:1891403200
Name:DI BACCO, EVANGELYN FAITH (DC)
Entity Type:Individual
Prefix:DR
First Name:EVANGELYN
Middle Name:FAITH
Last Name:DI BACCO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 RIO ROBLES E UNIT 209
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-1667
Mailing Address - Country:US
Mailing Address - Phone:408-242-5136
Mailing Address - Fax:
Practice Address - Street 1:2421 PARK BLVD STE B205
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1956
Practice Address - Country:US
Practice Address - Phone:408-248-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor