Provider Demographics
NPI:1194079194
Name:CALIFORNIA CHIROPRACTIC WELLNESS CORPORATION
Entity type:Organization
Organization Name:CALIFORNIA CHIROPRACTIC WELLNESS CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-960-4236
Mailing Address - Street 1:6839 FIVE STAR BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677
Mailing Address - Country:US
Mailing Address - Phone:408-960-4236
Mailing Address - Fax:
Practice Address - Street 1:6839 FIVE STAR BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677
Practice Address - Country:US
Practice Address - Phone:408-960-4236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-31678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty