Provider Demographics
NPI:1063598076
Name:IRVINE, MICHELL (DC)
Entity type:Individual
Prefix:MRS
First Name:MICHELL
Middle Name:
Last Name:IRVINE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NORTH PROSPECT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-374-9710
Mailing Address - Fax:310-374-6626
Practice Address - Street 1:520 N PROSPECT AVE STE 201
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3042
Practice Address - Country:US
Practice Address - Phone:310-374-9710
Practice Address - Fax:310-374-6626
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19718111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC19718Medicare UPIN