Provider Demographics
NPI:1922302314
Name:PREMIER HEALTH CARE CHIROPRACTIC & WELLNESS
Entity Type:Organization
Organization Name:PREMIER HEALTH CARE CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPERO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-492-7488
Mailing Address - Street 1:1001 AVENIDA PICO
Mailing Address - Street 2:SUITE C460
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6957
Mailing Address - Country:US
Mailing Address - Phone:949-492-7488
Mailing Address - Fax:949-492-6658
Practice Address - Street 1:1238 PUERTA DEL SOL STE 1A
Practice Address - Street 2:1A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6310
Practice Address - Country:US
Practice Address - Phone:949-492-7488
Practice Address - Fax:949-492-6658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADJ451AOtherMEDICARE PTAN