Healthcare Provider Details

I. General information

NPI: 1417033127
Provider Name (Legal Business Name): AZEVEDO CHIROPRACTIC, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 WEST ST
CAMBRIA CA
93428-3023
US

IV. Provider business mailing address

4070 WEST ST
CAMBRIA CA
93428-3023
US

V. Phone/Fax

Practice location:
  • Phone: 805-927-1055
  • Fax: 805-927-1701
Mailing address:
  • Phone: 805-927-1055
  • Fax: 805-927-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC27895
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC12352
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT29969
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT35580
License Number StateCA

VIII. Authorized Official

Name: KIRK J. AZEVEDO
Title or Position: PRESIDENT /CEO
Credential: D.C.
Phone: 805-927-1055