=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164453460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE CHRISTOPHERSON D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 06/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1502 N. COAST HIGHWAY
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-497-3212
-----------------------------------------------------
Fax | 949-497-1564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1278 GLENNEYRE ST STE 233
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-497-3212
-----------------------------------------------------
Fax | 949-497-1564
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NX0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Chiropractor
-----------------------------------------------------
License Number | DC18358
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 18358
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------