Healthcare Provider Details

I. General information

NPI: 1821086612
Provider Name (Legal Business Name): MICHAEL L CLOSE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 N FAIRFAX AVE
WEST HOLLYWOOD CA
90046-6103
US

IV. Provider business mailing address

1042 N FAIRFAX AVE
WEST HOLLYWOOD CA
90046-6103
US

V. Phone/Fax

Practice location:
  • Phone: 323-656-4194
  • Fax: 323-656-4151
Mailing address:
  • Phone: 323-244-8926
  • Fax: 323-656-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC26616
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: