Healthcare Provider Details

I. General information

NPI: 1154178085
Provider Name (Legal Business Name): VINCENT ANTHONY ANDERSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17811 SKY PARK CIR STE E
IRVINE CA
92614-6109
US

IV. Provider business mailing address

351 SAN TROPEZ CT
LAGUNA BEACH CA
92651-4433
US

V. Phone/Fax

Practice location:
  • Phone: 480-793-0652
  • Fax:
Mailing address:
  • Phone: 480-793-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number35216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: