=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215266937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LADERA CHIROPRACTIC AND WELLNESS, KHREICH AND CISNEROS CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2009
-----------------------------------------------------
Last Update Date | 12/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 CORPORATE DR STE C5
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-429-8787
-----------------------------------------------------
Fax | 949-429-8077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 CORPORATE DR STE C5
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-429-8787
-----------------------------------------------------
Fax | 949-429-8077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. JEAN-PIERRE NABIH KHREICH
-----------------------------------------------------
Credential | D.C., Q.M.E.
-----------------------------------------------------
Telephone | 949-429-8787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------