Healthcare Provider Details

I. General information

NPI: 1972654887
Provider Name (Legal Business Name): BODY TECH SPORTS & REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 W CHAPMAN AVE SUITE 204
ORANGE CA
92868-2862
US

IV. Provider business mailing address

PO BOX 20252
FOUNTAIN VALLEY CA
92728-0252
US

V. Phone/Fax

Practice location:
  • Phone: 714-308-5087
  • Fax: 714-289-4698
Mailing address:
  • Phone: 714-308-5087
  • Fax: 714-289-4698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK WILLIAM BENNALLACK
Title or Position: OWNER
Credential: D.C., CCRN
Phone: 714-308-5087