Provider Demographics
NPI:1922270990
Name:NATOMA STATION CHIROPRACTIC
Entity Type:Organization
Organization Name:NATOMA STATION CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAZAC
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:916-985-7575
Mailing Address - Street 1:231 BLUE RAVINE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3893
Mailing Address - Country:US
Mailing Address - Phone:916-985-7575
Mailing Address - Fax:
Practice Address - Street 1:231 BLUE RAVINE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3893
Practice Address - Country:US
Practice Address - Phone:916-985-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26511111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ62244ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ18250ZMedicare PIN