Provider Demographics
NPI:1316259377
Name:WINE COUNTRY CHIROPRACTIC MARK S. BANASIAK DC INC. A PROFESSIONAL CORP
Entity type:Organization
Organization Name:WINE COUNTRY CHIROPRACTIC MARK S. BANASIAK DC INC. A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANASIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-587-2225
Mailing Address - Street 1:29377 RANCHO CALIFORNIA RD
Mailing Address - Street 2:SUITE# 106
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27555 YNEZ RD STE 350
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4688
Practice Address - Country:US
Practice Address - Phone:951-587-2225
Practice Address - Fax:951-365-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ63647YOtherBLUE SHIELD