Healthcare Provider Details

I. General information

NPI: 1528506540
Provider Name (Legal Business Name): IAN FITZ-GIBBON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N BROADWAY
SANTA ANA CA
92706-2656
US

IV. Provider business mailing address

2615 RAQUETA
NEWPORT BEACH CA
92660-3510
US

V. Phone/Fax

Practice location:
  • Phone: 949-293-1610
  • Fax:
Mailing address:
  • Phone: 949-293-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: IAN FITZ-GIBBON
Title or Position: OWNER
Credential:
Phone: 949-293-1610