Provider Demographics
NPI:1699830620
Name:VANDEUSEN CHIROPRACTIC, INC
Entity type:Organization
Organization Name:VANDEUSEN CHIROPRACTIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DEUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-584-9888
Mailing Address - Street 1:1500 ADAMS AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3819
Mailing Address - Country:US
Mailing Address - Phone:714-556-6966
Mailing Address - Fax:714-242-1925
Practice Address - Street 1:1500 ADAMS AVE STE 306
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3819
Practice Address - Country:US
Practice Address - Phone:714-556-6966
Practice Address - Fax:714-242-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18988Medicare ID - Type UnspecifiedPRACITCE ID NUMBER FOR ME