Healthcare Provider Details

I. General information

NPI: 1790238632
Provider Name (Legal Business Name): ELITE CHIROPRACTIC SPORT REHAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 NEWPORT BLVD
COSTA MESA CA
92627-2161
US

IV. Provider business mailing address

2013 NEWPORT BLVD
COSTA MESA CA
92627-2161
US

V. Phone/Fax

Practice location:
  • Phone: 951-699-0303
  • Fax:
Mailing address:
  • Phone: 951-699-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DAVID SOLOWAY
Title or Position: OWNER
Credential: DC
Phone: 951-699-0303