Healthcare Provider Details

I. General information

NPI: 1992955215
Provider Name (Legal Business Name): DOCTOR O INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BAKER ST E SUITE 100
COSTA MESA CA
92626-4509
US

IV. Provider business mailing address

125 BAKER ST E SUITE 100
COSTA MESA CA
92626-4509
US

V. Phone/Fax

Practice location:
  • Phone: 949-813-2196
  • Fax:
Mailing address:
  • Phone: 949-813-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC23343
License Number StateCA

VIII. Authorized Official

Name: TERRY T OGINO
Title or Position: PRESIDENT
Credential: DC
Phone: 949-813-2196