Healthcare Provider Details

I. General information

NPI: 1275961302
Provider Name (Legal Business Name): DEFAZIO CHIROPRACTIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S ROBERTSON BLVD
BEVERLY HILLS CA
90211-2811
US

IV. Provider business mailing address

PO BOX 1176
CARDIFF CA
92007-7176
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-1775
  • Fax:
Mailing address:
  • Phone: 858-509-7999
  • Fax: 858-509-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC19752
License Number StateCA

VIII. Authorized Official

Name: PATRICK DEFAZIO
Title or Position: OWNER
Credential: D.C.
Phone: 310-659-1775