Provider Demographics
NPI:1972376598
Name:ALPHA SPORT AND PERFORMANCE CHIROPRACTIC
Entity type:Organization
Organization Name:ALPHA SPORT AND PERFORMANCE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-557-7208
Mailing Address - Street 1:1324 W BALBOA BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92661-1072
Mailing Address - Country:US
Mailing Address - Phone:218-349-9751
Mailing Address - Fax:
Practice Address - Street 1:333 E 17TH ST STE 15
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3220
Practice Address - Country:US
Practice Address - Phone:949-557-7208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty