Provider Demographics
NPI:1427074814
Name:STATELY, PAUL SCOTT (DC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:SCOTT
Last Name:STATELY
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 1:62 CORPORATE PARK
Mailing Address - Street 2:SUITE 235
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-3122
Mailing Address - Country:US
Mailing Address - Phone:949-955-1396
Mailing Address - Fax:949-955-1397
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:SUITE 235
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3122
Practice Address - Country:US
Practice Address - Phone:949-955-1396
Practice Address - Fax:949-955-1397
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U89855Medicare UPIN
DC0248420Medicare ID - Type Unspecified