Healthcare Provider Details

I. General information

NPI: 1568498970
Provider Name (Legal Business Name): DE DUBOVAY CHIROPRACTIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14340 BOLSA CHICA RD STE G
WESTMINSTER CA
92683
US

IV. Provider business mailing address

14340 BOLSA CHICA RD STE G
WESTMINSTER CA
92683-4868
US

V. Phone/Fax

Practice location:
  • Phone: 562-795-6680
  • Fax: 562-799-9575
Mailing address:
  • Phone: 562-795-6680
  • Fax: 562-799-9575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC16862
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC17394
License Number StateCA

VIII. Authorized Official

Name: DR. MARK DE DUBOVAY
Title or Position: PRESIDENT
Credential: D.C.
Phone: 562-795-6680