Healthcare Provider Details

I. General information

NPI: 1568028595
Provider Name (Legal Business Name): RAE MEYER BASTONI D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 CLYDESDALE CT STE. K
GRASS VALLEY CA
95945
US

IV. Provider business mailing address

124 CLYDESDALE CT STE. K
GRASS VALLEY CA
95945
US

V. Phone/Fax

Practice location:
  • Phone: 530-955-0065
  • Fax:
Mailing address:
  • Phone: 530-955-0065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number34507
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: