Provider Demographics
NPI:1396763470
Name:ANDERSON, PAULINE MARIE (DC, CCSP, IDE)
Entity type:Individual
Prefix:DR
First Name:PAULINE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC, CCSP, IDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E. SUNNYOAKS AVE
Mailing Address - Street 2:STE 213
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6639
Mailing Address - Country:US
Mailing Address - Phone:408-558-7998
Mailing Address - Fax:408-864-2051
Practice Address - Street 1:125 E. SUNNYOAKS AVE
Practice Address - Street 2:STE 213
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-6639
Practice Address - Country:US
Practice Address - Phone:408-558-7998
Practice Address - Fax:408-864-2051
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20898111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU39582Medicare UPIN
CADCO208980Medicare ID - Type Unspecified