1700334166 NPI number — FONTANA CHIROPRACTIC AND ACUPUNCTURE

Table of content: (NPI 1700334166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700334166 NPI number — FONTANA CHIROPRACTIC AND ACUPUNCTURE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FONTANA CHIROPRACTIC AND ACUPUNCTURE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700334166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20687 AMAR RD
Provider Second Line Business Mailing Address:
STE 2, BOX 240
Provider Business Mailing Address City Name:
WALNUT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91789-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13677 FOOTHILL BLVD
Provider Second Line Business Practice Location Address:
STE P
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-0505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-766-5397
Provider Business Practice Location Address Fax Number:
909-697-2274
Provider Enumeration Date:
09/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER/ACUPUNCTURIST
Authorized Official Telephone Number:
909-766-5397

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  33617 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , with the licence number: 17044 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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