Healthcare Provider Details

I. General information

NPI: 1154836054
Provider Name (Legal Business Name): LOYOLA CHIROPRACTIC, DR. BOLLMAN & DR. MARTIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 FREMONT AVE STE 155
LOS ALTOS CA
94024-6049
US

IV. Provider business mailing address

1000 FREMONT AVE STE 155
LOS ALTOS CA
94024-6049
US

V. Phone/Fax

Practice location:
  • Phone: 408-773-9165
  • Fax:
Mailing address:
  • Phone: 408-773-9165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. AMBER JO BOLLMAN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 408-599-4637