MEDICARE: PACIFIC EMPIRE CHIROPRACTIC A PROFESSIONAL CHIROPRACTIC CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC21111	CA

General Provider Information

NPI Number	:	1043426166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC EMPIRE CHIROPRACTIC A PROFESSIONAL CHIROPRACTIC CORPORATION

Provider Business Mailing Address
First Line	:	4590 RIVERSIDE DR
Second Line	:	SUITE B
City	:	CHINO
State	:	CA
Zip	:	91710-3980
Country	:	US
Telephone Number	:	909-464-9880
Fax Number	:	909-591-4720

Provider Business Practice Location Address
First Line	:	4590 RIVERSIDE DR
Second Line	:	SUITE B
City	:	CHINO
State	:	CA
Zip	:	91710-3980
Country	:	US
Telephone Number	:	909-464-9880
Fax Number	:	909-591-4720

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY L SANNES
Credential	:	DC
Telephone Number	:	909-464-9880

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	07/28/2009

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