Healthcare Provider Details

I. General information

NPI: 1194737270
Provider Name (Legal Business Name): OC BACK & BODY DOCTORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17264 RED HILL AVE
IRVINE CA
92614-5628
US

IV. Provider business mailing address

17264 RED HILL AVE
IRVINE CA
92614-5628
US

V. Phone/Fax

Practice location:
  • Phone: 949-724-0011
  • Fax: 949-724-0012
Mailing address:
  • Phone: 949-724-0011
  • Fax: 949-724-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT28504
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC26277
License Number StateCA

VIII. Authorized Official

Name: DR. DESIREE DEANNE EDLUND
Title or Position: CLINIC DIRECTOR
Credential: D.C.
Phone: 949-724-0011