Provider Demographics
NPI:1104082247
Name:VON FLOTOW, AUDREY P (DC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:P
Last Name:VON FLOTOW
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 1:10602 BOLSA AVE.
Mailing Address - Street 2:#5
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5259
Mailing Address - Country:US
Mailing Address - Phone:714-554-8357
Mailing Address - Fax:714-554-1001
Practice Address - Street 1:10602 BOLSA AVE.
Practice Address - Street 2:#5
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-5259
Practice Address - Country:US
Practice Address - Phone:714-554-8357
Practice Address - Fax:714-554-1001
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC16082Medicare PIN