Provider Demographics
NPI:1720158140
Name:HERNANDEZ, JOSE (DC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 LINDA VISTA DR
Mailing Address - Street 2:STE. 102
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-3819
Mailing Address - Country:US
Mailing Address - Phone:760-591-4878
Mailing Address - Fax:760-591-7878
Practice Address - Street 1:1125 LINDA VISTA DR
Practice Address - Street 2:STE. 102
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-3819
Practice Address - Country:US
Practice Address - Phone:760-591-4878
Practice Address - Fax:760-591-7878
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28894111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA455620689OtherNEW TAX IDENTIFICATION NUMBER
V06914Medicare UPIN