Provider Demographics
NPI:1992051650
Name:SIVANANDA, NATHAN (DC)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:SIVANANDA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 S MOUNT SHASTA BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2764
Mailing Address - Country:US
Mailing Address - Phone:530-926-1072
Mailing Address - Fax:530-926-1072
Practice Address - Street 1:1180 S MOUNT SHASTA BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2764
Practice Address - Country:US
Practice Address - Phone:530-926-1072
Practice Address - Fax:530-926-1072
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC022167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor