Provider Demographics
NPI:1154428019
Name:CUSIMANO, TRACIE MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:MARIE
Last Name:CUSIMANO
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 1:7561 CENTER AVE
Mailing Address - Street 2:UNIT 26
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3053
Mailing Address - Country:US
Mailing Address - Phone:714-840-2273
Mailing Address - Fax:
Practice Address - Street 1:7561 CENTER AVE
Practice Address - Street 2:UNIT 26
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3053
Practice Address - Country:US
Practice Address - Phone:714-840-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-26370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300035103OtherTAX ID NUMBER
CADC26370Medicare ID - Type Unspecified