Provider Demographics
NPI:1972627735
Name:VALENZUELA, JOHN RED EAGLE (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RED EAGLE
Last Name:VALENZUELA
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 1:1525 CUSHMAN ST
Mailing Address - Street 2:SUITE F.
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5519
Mailing Address - Country:US
Mailing Address - Phone:831-637-8099
Mailing Address - Fax:831-637-8226
Practice Address - Street 1:1525 CUSHMAN ST
Practice Address - Street 2:SUITE F.
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5519
Practice Address - Country:US
Practice Address - Phone:831-637-8099
Practice Address - Fax:831-637-8226
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0262550111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC026255OtherCHIROPRACTIC LICENSE
CA8775911587Medicare ID - Type Unspecified