Healthcare Provider Details

I. General information

NPI: 1740620483
Provider Name (Legal Business Name): ANDREA Y VIDAURRE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12062 VALLEY VIEW ST SUITE 133
GARDEN GROVE CA
92845-1737
US

IV. Provider business mailing address

12062 VALLEY VIEW ST SUITE 133
GARDEN GROVE CA
92845-1737
US

V. Phone/Fax

Practice location:
  • Phone: 714-906-3933
  • Fax: 714-892-9171
Mailing address:
  • Phone: 714-906-3933
  • Fax: 714-892-9171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number32647
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: