Healthcare Provider Details

I. General information

NPI: 1700334166
Provider Name (Legal Business Name): FONTANA CHIROPRACTIC AND ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13677 FOOTHILL BLVD STE P
FONTANA CA
92335-0505
US

IV. Provider business mailing address

20687 AMAR RD STE 2, BOX 240
WALNUT CA
91789-5044
US

V. Phone/Fax

Practice location:
  • Phone: 909-766-5397
  • Fax: 909-697-2274
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number33617
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17044
License Number StateCA

VIII. Authorized Official

Name: MICHAEL MARK
Title or Position: CO-OWNER/ACUPUNCTURIST
Credential: LA.C
Phone: 909-766-5397