=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154909794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFECTLY ALIGNED CHIROPRACTIC, A NISSENBAUM PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2021
-----------------------------------------------------
Last Update Date | 04/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 LAUREL ST STE D
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-226-8348
-----------------------------------------------------
Fax | 650-666-6747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 LAUREL ST STE D
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-226-8348
-----------------------------------------------------
Fax | 650-666-6747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SCOTT DAVID NISSENBAUM
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 650-226-8348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------