Provider Demographics
NPI:1992979538
Name:MY CENTER FOR CHIROPRACTIC & ANTI-AGING MEDICINE INC
Entity type:Organization
Organization Name:MY CENTER FOR CHIROPRACTIC & ANTI-AGING MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:MANAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-364-5656
Mailing Address - Street 1:26990 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6548
Mailing Address - Country:US
Mailing Address - Phone:949-364-5656
Mailing Address - Fax:
Practice Address - Street 1:26990 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6548
Practice Address - Country:US
Practice Address - Phone:949-364-5656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14686111N00000X
CAA60570208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A605700OtherBCBS
CADC0146860OtherBCBS