Provider Demographics
NPI:1184987729
Name:PONTIOUS CHIROPRACTIC PROF. CORP.
Entity type:Organization
Organization Name:PONTIOUS CHIROPRACTIC PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JESS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:PONTIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:925-648-4550
Mailing Address - Street 1:9500 CROW CANYON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-1188
Mailing Address - Country:US
Mailing Address - Phone:925-648-4550
Mailing Address - Fax:925-648-4553
Practice Address - Street 1:9500 CROW CANYON RD
Practice Address - Street 2:SUITE C
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-1188
Practice Address - Country:US
Practice Address - Phone:925-648-4550
Practice Address - Fax:925-648-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18921111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGM926AMedicare PIN