=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427552397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEO CHIROPRACTIC UNITED POURARBAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 03/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S HICKORY ST STE 116
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025-4360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-228-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16035 WIZARD WAY
-----------------------------------------------------
City | VALLEY CENTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92082-5326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-228-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PEJMAN POURARBAB
-----------------------------------------------------
Credential | DC,CPT
-----------------------------------------------------
Telephone | 619-228-2288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 7052
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 3729
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 32110
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------