Provider Demographics
NPI:1992029946
Name:IWANOFF CHIROPRACTIC
Entity type:Organization
Organization Name:IWANOFF CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:IWANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:818-707-2225
Mailing Address - Street 1:30423 CANWOOD ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2082
Mailing Address - Country:US
Mailing Address - Phone:818-707-2225
Mailing Address - Fax:818-991-9070
Practice Address - Street 1:30423 CANWOOD ST
Practice Address - Street 2:SUITE 225
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2082
Practice Address - Country:US
Practice Address - Phone:818-707-2225
Practice Address - Fax:818-991-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC13558Medicare UPIN