1114465986 NPI number — CRAIG A STUTZMAN CHIROPRACTIC CORPORATION

Table of content: (NPI 1114465986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114465986 NPI number — CRAIG A STUTZMAN CHIROPRACTIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG A STUTZMAN CHIROPRACTIC CORPORATION
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:
1114465986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 GEMA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN CLEMENTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92672-9408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-412-9366
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23695 BIRTCHER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92630-1782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-586-8525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
STUTZMAN
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
949-412-9366

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC25811 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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