Provider Demographics
NPI:1992945844
Name:CEDAR CHIROPRACTIC, DR. JOHNNY MANSOUR, D.C., PROF. CORP
Entity type:Organization
Organization Name:CEDAR CHIROPRACTIC, DR. JOHNNY MANSOUR, D.C., PROF. CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-937-6767
Mailing Address - Street 1:1801 EXCISE AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8554
Mailing Address - Country:US
Mailing Address - Phone:909-937-6767
Mailing Address - Fax:909-937-0353
Practice Address - Street 1:1801 EXCISE AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8554
Practice Address - Country:US
Practice Address - Phone:909-937-6767
Practice Address - Fax:909-937-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25895261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0258950Medicare PIN
CAV05363Medicare UPIN