Provider Demographics
NPI:1588716153
Name:GOTTLIEB CHIROPRACTIC INC
Entity type:Organization
Organization Name:GOTTLIEB CHIROPRACTIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:619-291-5433
Mailing Address - Street 1:1452 UNIVERSITY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-291-5433
Mailing Address - Fax:619-209-3608
Practice Address - Street 1:1452 UNIVERSITY AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-291-5433
Practice Address - Fax:619-209-3608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26726111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
488829Medicare UPIN
CADC26726Medicare ID - Type Unspecified