Provider Demographics
NPI:1063730604
Name:ADVANCED CHIROPRATIC AND SPORTS CARE LLC
Entity type:Organization
Organization Name:ADVANCED CHIROPRATIC AND SPORTS CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:HONAKER
Authorized Official - Last Name:ZIMMERER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-244-7622
Mailing Address - Street 1:31610 RAILROAD CANYON RD STE 4
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9454
Mailing Address - Country:US
Mailing Address - Phone:951-244-7622
Mailing Address - Fax:951-246-2657
Practice Address - Street 1:31610 RAILROAD CANYON RD STE 4
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9454
Practice Address - Country:US
Practice Address - Phone:951-244-7622
Practice Address - Fax:951-246-2657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17619111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty