=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144416314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM EDWARD GEBROSKY CHIROPRACTOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 09/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 DOVE ST SUITE 900
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-455-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 DOVE ST SUITE 900
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-455-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC19127
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------