Provider Demographics
NPI:1104990787
Name:ANGELA IACOVINO CHIROPRACTIC, INC
Entity type:Organization
Organization Name:ANGELA IACOVINO CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER D.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:CERICE
Authorized Official - Last Name:IACOVINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-642-8193
Mailing Address - Street 1:901 DOVER DR
Mailing Address - Street 2:SUITE 234
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5538
Mailing Address - Country:US
Mailing Address - Phone:949-642-8193
Mailing Address - Fax:949-642-8195
Practice Address - Street 1:901 DOVER DR
Practice Address - Street 2:SUITE 234
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5538
Practice Address - Country:US
Practice Address - Phone:949-642-8193
Practice Address - Fax:949-642-8195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26556111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC26556OtherCOMMERCIAL
CADC26556OtherPPO
CADC0265560OtherBLUE CROSS BLUE SHIELD
CADC0265560OtherBLUE SHIELD
CADC26556OtherTRICARE
CADC26556OtherBLUE CROSS
CADC26556Medicaid
CADC26556OtherHMO