Healthcare Provider Details

I. General information

NPI: 1750424446
Provider Name (Legal Business Name): GLEN PATRICK ALIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30320 RANCHO VIEJO RD STE 103
SAN JUAN CAPISTRANO CA
92675-1582
US

IV. Provider business mailing address

30320 RANCHO VIEJO RD STE 103
SAN JUAN CAPISTRANO CA
92675-1582
US

V. Phone/Fax

Practice location:
  • Phone: 949-218-4520
  • Fax: 949-218-4172
Mailing address:
  • Phone: 949-218-4520
  • Fax: 949-218-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC26006
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: