Healthcare Provider Details

I. General information

NPI: 1548393028
Provider Name (Legal Business Name): MARIOS C MICHAEL DC, CNS, DAAPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N. LAKE AVE. SUITE 102
PASADENA CA
91101
US

IV. Provider business mailing address

424 N. LAKE AVE. SUITE 102
PASADENA CA
91101
US

V. Phone/Fax

Practice location:
  • Phone: 626-440-7406
  • Fax: 866-379-0950
Mailing address:
  • Phone: 626-440-7406
  • Fax: 866-379-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC27129
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: