Provider Demographics
NPI:1649662610
Name:CONNOR UPPER CERVICAL CHIRO OF SO CAL
Entity type:Organization
Organization Name:CONNOR UPPER CERVICAL CHIRO OF SO CAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-642-5660
Mailing Address - Street 1:485 E 17TH ST
Mailing Address - Street 2:510
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:485 E 17TH ST
Practice Address - Street 2:510
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3265
Practice Address - Country:US
Practice Address - Phone:949-642-5660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABE869Medicare PIN