Provider Demographics
NPI:1780754325
Name:TEBBE, MICHAEL GAVIN (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GAVIN
Last Name:TEBBE
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 1:10801 NATIONAL BLVD
Mailing Address - Street 2:STE 340
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4142
Mailing Address - Country:US
Mailing Address - Phone:424-259-1432
Mailing Address - Fax:
Practice Address - Street 1:10801 NATIONAL BLVD
Practice Address - Street 2:STE 340
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4142
Practice Address - Country:US
Practice Address - Phone:424-259-1432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30255111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor