Provider Demographics
NPI:1992013882
Name:PAUL S STATELY D C INC
Entity Type:Organization
Organization Name:PAUL S STATELY D C INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:STATELY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-645-6325
Mailing Address - Street 1:275 VICTORIA ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1906
Mailing Address - Country:US
Mailing Address - Phone:949-645-6325
Mailing Address - Fax:949-645-6322
Practice Address - Street 1:275 VICTORIA ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1906
Practice Address - Country:US
Practice Address - Phone:949-645-6325
Practice Address - Fax:949-645-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-24842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000500201Medicare UPIN