Healthcare Provider Details

I. General information

NPI: 1275635575
Provider Name (Legal Business Name): ANGELA CERICE IACOVINO D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DOVER DR SUITE 234
NEWPORT BEACH CA
92660-5538
US

IV. Provider business mailing address

901 DOVER DRIVE, SUITE 234
NEWPORT BEACH CA
92660-5515
US

V. Phone/Fax

Practice location:
  • Phone: 949-642-8193
  • Fax: 949-325-0817
Mailing address:
  • Phone: 949-642-8193
  • Fax: 949-325-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC26556
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC26556
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC26556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: