Provider Demographics
NPI:1952526238
Name:RENEE M. DAVIDSON, DC A CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:RENEE M. DAVIDSON, DC A CHIROPRACTIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:323-664-6003
Mailing Address - Street 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:2107 HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2003
Practice Address - Country:US
Practice Address - Phone:323-664-6003
Practice Address - Fax:323-664-8931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13996111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0139960OtherBLUE SHIELD
CADC0139960OtherBLUE SHIELD
CAU08425Medicare UPIN