Provider Demographics
NPI:1336255405
Name:BROWN, PHILLIP DALE (DC)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DALE
Last Name:BROWN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:16168 BEACH BOULEVARD
Mailing Address - Street 2:#135
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3879
Mailing Address - Country:US
Mailing Address - Phone:714-841-5588
Mailing Address - Fax:714-841-2564
Practice Address - Street 1:16168 BEACH BLVD
Practice Address - Street 2:#135
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3879
Practice Address - Country:US
Practice Address - Phone:714-841-5588
Practice Address - Fax:714-841-2564
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC20530111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
421178Medicare UPIN