Provider Demographics
NPI:1528346285
Name:TSAMOUTALIDIS CHIROPRACTIC CORPORATIO
Entity type:Organization
Organization Name:TSAMOUTALIDIS CHIROPRACTIC CORPORATIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KONSTANTINOS
Authorized Official - Middle Name:
Authorized Official - Last Name:TSAMOUTALIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-314-3088
Mailing Address - Street 1:14 TRANTO DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1508
Mailing Address - Country:US
Mailing Address - Phone:951-314-3088
Mailing Address - Fax:951-840-2320
Practice Address - Street 1:21139 NEWPORT COAST DR
Practice Address - Street 2:
Practice Address - City:NEWPORT COAST
Practice Address - State:CA
Practice Address - Zip Code:92657-1122
Practice Address - Country:US
Practice Address - Phone:951-314-3088
Practice Address - Fax:951-840-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty