Provider Demographics
NPI:1215235577
Name:GUEDEA, MIGUEL ANTONIO (DC)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANTONIO
Last Name:GUEDEA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W 5TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2700
Mailing Address - Country:US
Mailing Address - Phone:310-732-0029
Mailing Address - Fax:310-732-0039
Practice Address - Street 1:302 W 5TH ST
Practice Address - Street 2:STE 101
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2700
Practice Address - Country:US
Practice Address - Phone:310-732-0029
Practice Address - Fax:310-732-0039
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 31751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor